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V 


DISEASES    OF   THE    COLON 
AND  THEIR  SURGICAL  TREATMENT 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/diseasesofcolontOOIock 


DISEASES  OE  THE  COLON 

AND    tiip:ir   surgical    treatment 


i FOUNDED    ON    THE    JACKSON/AN    ESSAY    FOR     iqag.) 


BY 

P.     LOCKHART     MUMMERY.    F.R.C.S.  Eng., 

B.A..    M.B..    B.C.  CANTAB.. 

Jacksojiian.  Prizeman  aiui  laic  f/untiiian  Pro/isso'\   Royal  College  n/  Su}-genns : 

Senior  Assistant  Sin-gcon  St.  Mark's  Hospital  for  Cinteer,   Fistula,  ami  oilier  Diseases 

of  the  Rectum;  and  Senior  Surgeon  to  Out-Fatients,    The  Queen's  Hospital 

for  Children,  London 


ILLUSTRATED     BY     COLOURED     AND     OTHER      PLATES. 

AND    NUMEROUS    FIGURES    IN    THE   TEXT,   MANY    OF  WHICH   ARE   REPRODUCED 

FROM     THE    AUTHORS    SKETCHES 


^'E^V     YORK  : 

WILLIAM     WOOD     AND     CO.MPANY. 

MDCCCCX. 


JOHN    WRIGHT    AND    SONS   LTD. 
PRINTERS    AND    I'UHI.ISUILKS.    BRISTOL. 

i  -^  _    I  •g'  i'  U- 


^  PREFACE 

^  Until  comparatively  recently,  diseases  of  the  colon   had 

,~  received  but  scant  attention,   and  with   the  exception  of 

^  ■  cancer  and  amoebic  dysentery,  little  was  known  about  the 


Q 


pathological  conditions  which  occur  in  this  portion  of  the 
alimentary  tract.  Everybody  was  treating  constipation, 
but  few  knew  anything  about  its  causes.  Within  the  last 
few  years,  however,  chiefly  as  the  result  of  better  methods 
of  diagnosis,  our  knowledge  with  regard  to  diseases  of  the 
colon  has  been  much  increased. 

The  subject  is  one  of  considerable  importance,  for  every- 
thing points  to  the  conclusion  that  diseases  and  abnormalities 
of  the  colon  are  becoming  more  frequent.  This  is  probably 
to  be  attributed  mainly  to  modern  methods  of  dietary 
more  than  to  any  other  factor.  Among  uncivilized  races 
of  mankind,  the  alimentary  system  has  to  digest  and  deal 
with  food  in  which  digestible  and  indigestible  materials 
are  about  equally  mixed.  But  under  our  present  high 
state  of  civilization,  foods,  both  animal  and  vegetable, 
are  specially  grown.  The  animals  which  supply  our  meat 
are  specially  bred  and  cared  for  to  render  it  free  from 
gristle,  and  the  vegetables  are  cultivated  to  contain  but 
little  cellulose,  and  are  further  prepared,  especially  in  the 
case  of  bread,  to  reduce  this  ingredient  to  the  very 
minimum.  Under  these  conditions,  to  which  must  often 
be  added  a  sedentary  occupation,  the  normal  stimuli  to 
peristalsis  and  digestion  are  to  a  large  extent  absent.  And 
this,   combined  with   other  factors,   one   of  which   is   the 


vi  PREFACE 


modem  craze  for  patent  aperient  medicines,  favours  jthe 
production  of  disease  in  the  colon. 

This  book  is  founded  upon  the  Essay  which  was  awarded 
the  Jacksonian  Prize  for  igog  by  the  Royal  College  of 
Surgeons.  In  order  to  make  it  a  practical  and  useful  text- 
book, it  has  been  necessary  to  make  several  additions  to  the 
original  essay,  and  to  condense  some  of  the  chapters  dealing 
with  rare  conditions  of  the  bowel.  The  earlier  chapters  are 
devoted  to  the  anatomy  and  physiology  of  the  colon,  both 
in  health  and  disease.  The  subject  of  diagnosis  has  been 
very  thoroughly  discussed,  this  being  the  factor  presenting 
the  greatest  difficulty  in  dealing  with  disease  when  it  attacks 
the  colon.  Special  attention  also  has  been  paid  to  the 
effect  of  adhesions,  and  to  chronic  constipation  and 
obstruction  in  their  various  forms.  The  different  varieties 
of  colitis  are  fully  considered,  as  also  are  pericolitis  and 
cancer. 

The  closing  chapters  of  the  book  are  devoted  to  a 
description  of  the  various  operations  which  may  be 
performed  on  the  colon. 

I  have  to  offer  my  best  thanks  to  those  friends  who  have 
kindly  lent  me  blocks  or  illustrations. 

P.  L.  M. 

10,  Cavendish  Place,  W., 
May,  igio. 


CONTENTS 

CHAP.  PAGE 

I.  THE    ANATOMY    AND    DEVELOPMENT    OF    THE    COLON  -              I 

II.  PHYSIOLOGY    OF    THE    COLON                        -                       -  -                     I3 

III.  MORBID    PHYSIOLOGY    OF    THE    COLON              -                      -  -         28 

IV.  BACTERIOLOGY    OF    THE    COLON                  "                       "  "                    37 

V.  METHODS    OF    DIAGNOSIS                           -                        -                        -  "41 

VI.  CONGENITAL    ABNORMALITIES    OF    THE    COLON      -  -                      58 

VII.  VOLVULUS    OF    THE    COLON                    -                       -                       -  "76 

VIII.  .ADHESIONS    AND    KINKING    OF    THE    COLON              "  "                       93 

IX.  ENTEROPTOSIS      OF      THE      TRANSVERSE      COLON     AND  HERNIA 

OF    THE    COLON                             .                       .                       .  .  107 

X.  Intussusception           -                -               -               -  -     114 

XI.  CHRONIC    mucous    OR    MEMBRANOUS    COLITIS        -  -                  I27 

XII.  ULCERATIVE    COLITIS                                .                       .                       .  _       j-^ 

XIII.  PERICOLITIS                     -----  Ijg 

XIV.  TUBERCULOSIS    OF    THE    COLON                               -                       -  -       20I 
XV.  CHRONIC    CONSTIPATION    AND    F.ECAL    IMPACTION  -                  2l8 

XVI.  SIMPLE    STRICTURE    OF     THE     COLON     AND     EMBOLISM  OF     THE 

MESOCOLIC    VESSELS                -                       -                      -  -  233 

XVII.  SIMPLE    TUMOURS    OF    THE    COLON                       -                       -  -       237 

XVIII.  MALIGNANT    DISEASE    OF    THE    COLON                             -  -                   249 

XIX.  TRAUMATISM  -----       276 

XX.  COLOTOMY                         -----  280 

XXI.  APPENDICOSTOMY    AND    VALVULAR    C^COSTOMY              -  -       294 

XXII.  RESECTION    AND    ANASTOMOSIS    OF    THE     COLON  -  -                    302 


DISEASES    OF    THE    COLON 


Chapter  I. 

THE     ANATOMY    AND 
DEVELOPMENT    OF     THE     COLON 

THE  ANATOMY  OF  THE  COLON. 

IN  man,  the  colon  starts  in  the  right  lower  part  of  the  abdomen, 
and  passes  up  towards  the  liver,  then  across  towards  the 
spleen,  and  then  downwards  to  reach  the  rectum.  In  most 
carnivorous  animals,  however,  the  caecum  lies  under  the  liver, 
and  the  colon  passes  across  and  then  down,  having  the  shape 
of  the  letter  L  inverted,  the  colon  thus  being  much  shorter 
relatively  than  in  man.  In  man  the  commencement  of  the 
colon  forms  a  dilated  pouch,  called  the  caecum,  into  which  the 
small  bowel  opens  by  a  valve-like  opening.  The  caput  coli 
may  be  looked  upon  almost  as  a  second  stomach,  and  Prof. 
Keith  has  pointed  out  that  it  corresponds  both  embryologicalh' 
and  anatomically  to  the  stomach  as  regards  function.  It  has 
the  same  relationship  to  the  large  bowel  that  the  stomach  has 
to  the  small  bowel. 

In  some  animals  the  caecum  or  caput  coli  is  the  main  organ 
of  digestion  ;  while  in  others,  as  in  man,  the  stomach  has  this 
function. 

In  the  iguana,  the  orang-utang,  and  some  monkeys,  the 
caput  coli  forms  a  separate  viscus,  with  a  valve  between  it 
and  the  ileum,  and  also  between  it  and  the  colon  [Fig.  i). 

In  the  tapir,  although  there  is  no  such  perfect  valve  as  exists 
in  the  iguana,  there  is  a  circular  fold  forming  a  definite  division 
between  the  caput  coli  and  the  remainder  of  the  colon 

In  fishes  there  is  no  distinction  into  small  and  large  bowel. 
In  some  animals,  instead  of  the  caput  coli  being  dilated  to  form 
a  caecum,  there  are  pouches  connected  with  the  large  bowel  which 

I 


2  THE    ANATOMY 

doubtless  act  similarly.  Thus  in  the  hyrax  there  are  three 
so-called  caeca,  two  paired  and  one  single. 

In  the  lemur  {Perodicticus  patto)  a  very  curious  arrangement 
exists.  The  colon  is  folded  back  upon  itself  twice,  the  folds 
being  connected  by  a  delicate  mesenter\-. 

In  most  animals  the  descending  colon  joins  the  rectum  as  a 
more  or  less  straight  tube,  and  there  is  no  coil  like  the  sigmoid 
flexure  in  man. 

The  colon  extends  from  the  ileocaecal  valve  to  the  recto- 
sigmoidal  junction.  The  exact  position  of  this  latter  point 
has  been  rather  uncertain,  different  writers  having  taken 
different  points  for  the  junction  between  the  pehdc  colon  and 
the  rectum  ;    the  correct  anatomical  point,  however,  is  at  the 


Pig. 


-Diagrammatic  representation  of  the  Caeca  of  A,  Iguana  and  Orang-utang  ; 
B,  Tapir:    and  C,  HjTax. 


position  of  what  has  bj'  some  observers  been  called  the  sigmoido- 
rectal sphincter.  There  is  at  this  point  a  distinct  fold,  or 
narrowing  of  the  bowel  lumen,  which  can  easih"  be  seen  if  the 
bowel  is  examined  with  the  sigmoidoscope.  This  point  corres- 
ponds roughly  to  the  point  at  which  the  bowel  becomes 
fixed. 

The  length  of  the  colon  varies  considerabh'  in  different 
subjects.  The  average  length  is  about  22  inches.  j\Ir.  Lockwood, 
from  a  stud}^  of  dissecting-room  subjects,  found  the  usual  length 
to  be  22  inches,  the  longest  he  met  with  being  28  inches. 
Amussat  found  that  it  varied  from  18  inches  to  2  feet.  The 
average  length  of  the  ascending  colon  is  8  inches,  and  that  of 
the  descending  colon  8|  inches. 


OF    THE     COLON  3 

The  most  important  parts  of  the  colon  from  a  surgical  and 
pathological  standpoint  are  the  ileocaecal  angle,  the  transverse 
colon,  and  the  sigmoid  flexure. 

The  caecum  and  ascending  colon  are,  as  a  rule,  only  partly 
covered  by  peritoneum,  but  exceptionally  possess  a  mesentery  ; 
the  remainder  of  the  colon  has  a  more  or  less  complete  mesentery. 

The  Ileocaecal  Valve. — ^This  varies  considerably  in  different 
animals,  though  in  all  its  object  is  the  same,  namely,  to  prevent 
regurgitation  of  the  contents  of  the  caecum  into  the  ileum. 

In  man}'  animals  an  oblique  opening  is  depended  on,  somewhat 
similar  to  the  opening  of  the  ureter  into  the  bladder  in  man 
{Fig.  2). 

In  others,  notably  in  the  iguana,  tapir,  and  many  monkeys, 
the  valve  is  at  the  extremity  of  a  conical  papilla-like  projection 


Fig.  2.  Fig.  3- 

of  the  ileum  into  the  caecum,  any  tendency  towards  regurgitation 
resulting  in  the  sides  of  the  ileocaecal  opening  being  pushed 
together  {Fig.  3). 

In  man,  however,  and  in  some  animals,  there  is  a  definite 
muscular  sphincter,  and  it  is  upon  this,  rather  than  upon  the 
formation  of  the  opening,  that  its  integrity  as  a  valve  depends. 
In  the  bear,  ferret,  and  hedgehog  there  is  no  sphincter,  and  the 
mechanical  advantages  of  an  oblique  opening  are  depended 
upon. 

The  ileocaecal  sphincter  in  man  is  much  better  developed 
than  in  an}'  of  the  lower  animals.  Elhott  proved  that  there  is 
a  true  sphincter  in  the  cat,  and  was  able  to  investigate  its  action. 
He  found  that  stimulation  of  the  sympathetic  nerves  causes 
contraction  of  the  sphincter,  though  at  the  same  time  inhibiting 
the  circular  fibres  in  the  ileum  and  colon  adjoining.     In  the 


4  THE    ANATOMY 

cat  these  constrictor  fibres  come  from  the  13th  dorsal  and  ist 
and  2nd  lumbar  roots. 

Both  anaemia  and  the  application  of  adrenalin  caused  the  same 
effect  as  stimulation  of  the  sympathetic,  i.e.,  constriction. 

Removal  of  the  cord  abolished  the  power  to  keep  apart  the 
contents  of  the  ileum  and  colon. 

Blood-vessels  of  the  Colon, — The  arteries  of  the  colon  run  in 
a  circular  direction  round  the  bowel  from  the  mesenteric  border 
to  the  free  margin,  the  vessels  lying  roughly  parallel  to  one 
another.  The  arteries  of  the  wall  of  the  colon  do  not  anastomose 
freely  with  one  another,  and  in  consequence,  if  care  is  not  taken 
when  resecting  portions  of  the  large  bowel,  the  blood-supply  is 
easily  damaged,   and  sloughing  results.     For  this  reason  it  is 


Fis 


-Diagram  to  show  the  way  in  which  the  arteries  pass   from  the 
arterial  arcades  to  the  colon  wall. 


a  good  plan,  when  dividing  the  bowel,  to  make  the  division 
slightly  oblique,  so  that  rather  more  is  cut  away  at  the  free 
margin  than  on  the  attached  border  {Fig.  4).  This  insures  the 
whole  of  the  edge  of  the  divided  bowel  having  a  good  blood- 
supply.  The  different  parts  of  the  colon  differ  somewhat  as 
regards  the  arrangement  of  the  blood-vessels.  In  the  greater 
part  of  the  colon  the  arteries  anastomose  by  a  series  of  loops 
just  before  reaching  the  bowel ;  these  loops  lie  close  to  the 
mesenteric  border  of  the  bowel  and  form  a  free  anastomosis. 
In  the  sigmoid  flexure,  however,  the  arteries  usually  anastomose 
nearer  the  base  of  the  mesocolon,  and  then  pass  straight  to 
the  bowel ;  so  that  there  is,  as  a  rule,  no  free  anastomosis  to 
preserve  the  blood-supply  of  the  colon  when  the  mesosigmoid 


OF    THE    COLON  5 

is  cut  close  to  its  bowel  attachment.  This  is  an  important 
point  to  be  considered  when  planning  a  resection  of  any  part 
of  the  pelvic  colon. 

There  are  three  branches  of  the  superior  mesenteric  arterx^ 
to  the  colon — the  ileocolic,  the  colica  dextra,  and  the  colica 
media.  The  caecum  is  supplied  by  branches  from  all  these  three 
arteries. 

Mr.  Jamieson  and  Mr.  Dobson*  found  that  the  colica  dextra 


J^'ig-    S- — Diagram   of  the   cascal   angle,    showing    ileocfecal 
artery  and  its  branches. 

artery  is  a  direct  branch  of  the  superior  mesenteric  artery  in 
less  than  50  per  cent  of  cases.  In  about  30  per  cent  it  is  a 
branch  of  the  ileocohc. 

The  colica  media  artery  arises  from  the  superior  mesenteric, 
just  below  the  lower  border  of  the  pancreas,  and  passes  down- 
wards across  the  superior  mesenteric  vein  to  enter  the  transverse 
mesocolon.  Half-way  to  the  colon  it  divides  into  two  branches  ; 
these  again  divide  near  the  colon,  forming  a  series  of  arcades 
from  which  branches  pass  to  the  colon  wall.  The  largest  of 
these  arcades  lies  one  or  two  fingers'  breadth  from  the  bowel 
along  the  left  two-thirds  of  the  transverse  colon,  and  encloses 


*   Trans.  Roy.  Soc.  Med.,  Feb.  9,  1909. 


6  THE    ANATOMY 

a  large  area  of  mesocolon  containing  very  few  vessels.  The 
end  of  this  arcade  anastomoses  freely  with  a  branch  of  the 
inferior  mesenteric  artery. 

The  inferior  mesenteric  artery  leaves  the  aorta  behind  the 
duodenum  and  passes  downwards  across  the  aorta  and  left 
psoas  muscle.  It  gives  off  the  colica  sinistra  and  sigmoidea 
arteries  to  the  colon.  The  colica  sinistra,  which  is  the  most 
important,  leaves  the  parent  trunk  close  to  the  latter's  origin 


I^ig:  6. — Blood  supply  of  the  palvic  colon.     Note  that  the  anastomosis  occurs  some  way  from 
the  bowel  wall,  .ind  is  destroyed  by  cutting  the  mesocolon  close  to  the  bowel. 

from  the  aorta.  It  passes  upwards  across  the  kidney  towards 
the  splenic  flexure,  where  it  divides  to  anastomose  on  the  one 
hand  with  the  colica  media  artery  and  supply  the  left  part  of 
the  transverse  colon,  and  on  the  other  with  the  sigmoidea 
arteries  to  supply  the  descending  colon.  There  are  usually 
three  or  four  sigmoid  arteries  which  anastomose  with  each  other 
by  short  arcades  ;  the  lowest  anastomoses  with  the  superior 
hsemorrhoidal  artery. 


OF    THE    COLON  7 

The  method  of  this  last  anastomosis  is  important,  as  pointed 
out  by  Jamieson  and  Dobson    {Fig.  7). 

Lymphatics  of  the  Colon. — The  lymphatics  follow 
roughly  the  arteries  and  veins.  Jamieson  and  Dobson,  who 
have  made  a  careful  study  of  the  lymphatic  arrangements  of 
the  colon,  divide  the  lymphatic  glands  into  the  following  groups  : 

The  epicolic  glands,  which  lie  on  the  intestinal  wall  and  in 
the  appendices  epiploicse.  These  are  particularly  numerous  in 
the  pelvic  colon.     They  drain  into  the  next  two  groups. 

The  ■paracolic  glands,  which  lie  along  the  inner  edge  of  the 
gut  in  the  mesenteric  attachment  ;  and 


Pig-   7.— A,  Inferior  mesenteric  artery;  B,  ligature  without  destroying  anastomosis  ;  C,  ligatures 
breaking  the  anastomosis.      [Jamieson  and  Dobson,  Proc.  Roy.  Soc.  Med.,  Vol.  2,  1909,] 

The  intermediate  groups,  which  lie  along  the  arteries  and  at 
their  junctions. 

In  addition  to  these  groups  there  are  the  main  groups  into 
which  all  the  foregoing  drain.  There  are  three  main  groups  or 
chains  which  can  be  distinguished,  though  any  such  classification  is 
in  a  sense  arbitrary.      Nine  isolated  groups  of  glands  are  common. 

There  is  the  middle  colic  group,  which  lies  on  the  middle 
colic  artery  at  the  foot  of  the  transverse  mesocolon. 

The  left  colic  group  lies  partly  on  the  horizontal  portion  of 


8  THE    ANATOMY 

the  artery  near  its  origin,  and  partly  on  the  terminal  portion  of 
the  mesenteric  vein.  These  glands  drain  into  the  superior 
mesenteric,  coeliac,  and  lumbar  glands.  The  inferior  mesenteric 
group  lies  on  the  stem  of  the  inferior  mesenteric  artery  ;  its 
glands  drain  into,  and  may  almost  be  considered  as  forming  part 
of,  the  lumbar  glands.     It  is  this  chain  of  glands  which  drains 


J^i^.  8. — Diagram  showing  the  relation  of  the  colon  to  the 
abdominal  parietes. 


the  pelvic  colon.  It  is  important  to  notice  that  some  of  the  lym- 
phatics of  the  left  half  of  the  transverse  colon  drain  into  the  glands 
at  the  hilum  of  the  spleen,  passing  via  the  gastrocolic  omentum. 
Jamieson  and  Dobson  found  evidence  of  a  communication 
between  the  lymphatic  and  venous  systems  in  the  abdomen, 
though  they  were  unable  to  ascertain  at  what  particular  point 
this  occurred. 


PLATE    I 


THE      LYMPHATICS     OF     THE     COLON 

(Jamieson  and  Dobson,   Proc.  Roy.   Soc.  Med.  Vol.  ii.,  1909.) 


OF    THE    COLON  9 

The  Sigmoid  Flexure  or  Pelvic  Colon. — This  is  the 
mobile  portion  of  the  colon,  whicli  is  situated  between  the 
straight  and  fixed  descending  colon  and  the  fixed  rectum,  and 
the  average  length  is  17I  inches.  It  forms  a  loop  which,  in  a 
normal  man  in  the  erect  position,  lies  forward  and  falls 
across  the  front  of  the  rectum,  lying  partly  behind  the 
bladder  or  uterus,  and  partly  in  the  left  iliac  fossa.  It  has  a 
long  mesentery,  which  is  fan-shaped,  having  a  short  attachment 
3  inches  long,  situated  along  a  line  from  the  left  sacro-iliac 
synchondrosis  to  the  mid-line  of  the  sacrum. 

There  is  normally  a  slight  kink  or  angle  where  the  pelvic 
colon  joins  the  rectum,  but  this  is  pre^'ented  by  the  mesentery 
from  becoming  an  obstruction,  ^^'hen  the  mesosigmoid  is 
abnormal  or  has  become  stretched,  this  kink  is  much  exaggerated 
and  may  cause  a  considerable  degree  of  obstruction. 

THE  DEVELOPMENT  OF  THE  COLON. 

The  colon  begins  to  be  differentiated  from  the  rest  of  the 
alimentar-s'   canal   about   the   sixth   week   of   intra-uterine   life. 


/■'ig^g. — Diagram  of  three  stages  in  the  development  of  the  colon,  showing  how  the  caecum 
passes  from  the  left  to  the  right  side  of  the  ahdomen,  and  then  downwards  into  the  right 
iliac  fossa.     The  caecum  and  colon  are  coloured,  and  the  small  bowel  black. 


The  caecum  first  appears  as  a  lateral  protrusion  of  the  alimentary 
tube.  This  protrusion  forms  just  be3^ond  the  vitelline  duct, 
and  gradually  increases  in  size  except  at  its  blind  extremity, 
which  remains  narrow  and  becomes  the  vermiform  appendix. 
As  the  ahmentar}'  canal  increases  in  length  it  forms  a  loop,  the 
lower  limb  of  which  forais  the  colon,  which  thus  comes  to  be 


10  THE    DEVELOPMENT 

placed  transversely  in  the  peritoneal  cavity  tying  in  front  of 
the  commencement  of  the  small  intestine. 

In  the  third  and  fourth  month  of  intra-uterine  life  the  caecum 
lies  at  about  the  centre  of  the  abdomen,  while  the  remainder  of 
the  colon  lies  as  a  curved  tube  in  the  left  hypochondriac  and  left 
iliac  regions,  attached  by  a  mesentery  to  the  front  of  the  spine. 

As  the  alimentary  canal  increases  in  length  and  the  loop 
enlarges,  the  caecum  and  upper  part  of  the  colon  are  carried 
upwards  and  to  the  left,  and  then  over  to  the  right,  so  that  the 
caecum  comes  to  lie  under  the  liver  in  the  right  hypochondriac 
region.  At  this  stage  the  colon  resembles  that  found  in  the 
dog,  cat,  and  other  carnivorous  mammalia  in  whom  there  is  no 
ascending  colon. 

Later  still,  the  caecum  passes  downward  towards  the  right 
iliac  fossa.  In  the  eighth-month  foetus  the  caecum  is  just  below 
the  right  iliac  crest,  and  the  colon  forms  the  typical  inverted  U 
of  man.  The  causes  of  the  descent  of  the  caecum  into  the  right 
iliac  fossa  are  somewhat  uncertain,  but  it  has  been  pointed 
out  by  Mr.  Lockwood  that  in  the  eighth-month  foetus  there  is 
a  band  of  peritoneum  passing  from  the  right  testis  to  the  caecum 
close  to  the  termination  of  the  ileum,  and  he  has  suggested  it  as 
probable  that  the  caecum  is  carried  down  into  the  right  iliac 
fossa  by  the  descent  of  the  testicle.  Lockwood  lound  that 
in  the  female  foetus  there  is  a  similar  relationship  between  the 
right  ovar\^  and  the  caecum. 

The  probabihty  of  this  view  is  much  increased  by  the  fact 
that  imperfect  descent  of  the  Ccecum  is  frequently  accompanied 
by  undescended  testicle. 

Under  abnormal  conditions  the  colon  may  be  arrested  at 
any  stage  of  its  development,  in  which  case  the  foetal  condition 
will  persist  after  birth.  When  this  occurs  it  is  generally  the 
result  of  adhesions  having  formed  to  fix  the  colon  and  prevent 
its  descent.  Evidence  of  these  adhesions,  generally  formed  as 
the  result  of  some  inflammatory  condition  during  intra-uterine 
life,  are  usually  to  be  found  if  carefully  looked  for. 

It  will  be  obvious  that  if  the  progress  of  the  colon  is  arrested, 
it  may  be  found  in  any  of  the  following  positions,  according  to 
the  period  at  which  arrest  took  place. 

If  arrested  very  early,  the  caecum  may  be  outside  the  abdomen, 
and  the  colon  pass  as  an  almost  straight  tube  to  the  rectum. 
The  caecum  may  lie  in  the  central  or  left  upper  portion  of  the 


OF    THE    COLON 


II 


abdominal  cavity,  and  the  transverse  and  ascending  portions  of 
the  colon  be  missing. 

The  csecum  may  lie  under  the  liver  in  the  right  hypochondriac 
region,  so  that  the  condition  found  is  that  normally  present  in 
the  dog,  there  being  no  ascending  colon. 

Or  the  cjecum  ma}'  have  partly  descended,  but  not  reached 
the  right  iliac  fossa,  the  ascending  colon  being  very  short. 

Cases  are  recorded  in  which  all  these  conditions  have  persisted 
as  the  result  of  arrested  development,  and  will  be  referred  to 
in  dealing  with  congenital  abnormalities  of  the  colon. 

The  Development  of  the  Mesentery. — At  first,  the  whole 
alimentary  tract  possesses  a  mesentery,  which  increases  in 
length  with   the   growth   of  the   intestine,    except  in  the  case 


J^/£.    lo. — Diagrams  showing  the  development  of  the  great  omentum.     The  peritoneum 
is  shown  in  red.     (St.)  Stomach.     (C)  Colon. 


of  the  duodenum  and  the  ascending  and  descending  colon. 
The  caecum  and  the  ascending  and  descending  colon,  as  they 
grow,  push  themselves  between  the  layers  of  the  mesentery  so 
that  the  latter  becomes  to  a  large  extent  obliterated,  and  these 
portions  of  the  colon  normally  lose  their  mesentery  b^'  the 
time  development  is  complete. 

While  the  colon  is  passing  across  the  abdomen  to  reach  the 
right  hypochondriac  region,  it  possesses  a  common  mesentery 
with  the  small  intestine,  and  if  it  is  arrested  in  this  stage  of 


12  THE  DEVELOPMENT  OF  THE  COLON 

development  it  retains  this  arrangement  of  the  mesentery. 
In  cases  of  undescended  caecum  there  is  generally  a  long 
mesentery  to  the  right-hand  portion  of  the  colon,  which  enables 
it  to  become  twisted  and  form  a  volvulus. 

The  mesentery  of  the  transverse  colon  is  at  first  entirely 
separate  from  the  great  omentum  or  mesogastrium  (the  original 
mesentery  of  the  stomach)  lying  transversely  behind  it,  but 
the  two  membranes  fuse  about  the  fourth  month,  so  that  the 
transverse  colon  comes  to  lie  in  the  posterior  surface  of  the 
great  omentum  {Fig.  lo). 


13 


Chapter  II. 
PHYSIOLOGY    OF    THE    COLON. 

FUNCTIONS     OF     THE     LARGE     INTESTINE. 

Re-absorption  of  Water. — One  of  the  most  important 
functions  of  the  colon  is  to  prevent  loss  of  water  from  the  body. 
B\'  means  of  the  re-absorption  of  water  from  the  intestinal 
contents  which  occurs  in  the  colon,  the  body  is  protected  against 
the  loss  of  fluid  which  would  otherwise  take  place,  and  which, 
under  conditions  different  from  those  usualty  existing  at  the  present 
day,  would  seriously  prejudice  the  chances  of  the  individual  in 
the  struggle  for  existence.  Digestion  and  absorption  cannot  be 
carried  out  in  the  absence  of  water,  and  most  animals,  including 
man,  must  under  uncivilized  conditions  be  very  dependent  upon 
the  retention  of  moisture  or  fluid  within  the  tissues  for  long 
periods  without  the  necessity  of  replenishment.  To  this  end  it 
is  an  obvious  economy  to  remove  the  moisture  from  the  excreta 
before  their  dejection  from  the  body.  It  seems  reasonable  to 
suppose  that,  in  the  process  of  evolution,  material  advantage 
would  accrue  to  those  animals  which  were  best  able  to  preserve 
their  fluids  ;  and  it  is  quite  obvious  that  a  considerable  loss  of 
water  would  occur  if  the  dejecta  were  as  fluid  as  the  contents  of 
the  ileum.  In  birds  the  body  fluids  are  even  better  preserved 
than  in  mammals,  for  the  uric  acid  is  got  rid  of  in  a  semi-solid 
state  with  the  dejecta  of  the  bowel. 

This  is  a  distinct  economy  of  the  amount  of  fluid,  and  would 
seem  to  be  of  advantage  in  lessening  the  weight  which  has  to  be 
supported  in  the  air,  while,  at  the  same  time,  doing  away  with 
the  necessity  for  freiquent  replenishment. 

In  cases  where,  for  the  relief  of  some  diseased  condition,  a 
right  inguinal  colotomy  has  been  performed  so  that  the  dejecta 
escape  at  the  termination  of  the  ileum  instead  of  first  passing 
through  the  colon,  the  patient  always  suffers  considerably  from 
thirst,  and  it  is  quite  obvious  that  a  great  waste  of  body  fluid  is 
occurring. 


14  NERVE     SUPPLY 

Absorption  of  Food  Constituents. — In  addition  to  its 
function  of  removing  moisture  from  the  excreta,  there  can  be  no 
doubt  that  the  colon  absorbs  some  of  the  food  constituents  of  its 
contents.  There  is  abundant  evidence  that  the  waUs  of  the 
caecum  and  colon  can  absorb  fats,  and  it  seems  almost  certain 
that  carbohydrates  and  even  proteids  can  also  be  absorbed. 

There  has  recently  been  much  dispute  as  to  the  value  of  the 
colon,  and  there  are  not  wanting  those  who  maintain  that  we 
should  be  better  and  healthier  if  we  possessed  no  colon.  The 
fact  that  human  beings  can  live  without  a  colon  is,  however,  no 
proof  of  its  uselessness,  and  at  present  the  evidence  brought 
forward  to  prove  that  the  colon  is  a  useless  and  effete  portion  of 
the  alimentary  tract  is  anything  but  convincing.  Under  condi- 
tions of  modern  civilization  it  is  undoubtedly  possible  for  human 
beings  to  live  without  a  colon,  and  perhaps  even  for  it  not  to  be 
missed  ;  but  man  was  not  designed  to  live  in  a  London  flat  with 
servants  and  a  banking  account,  and  this  can  hardly,  therefore, 
be  taken  as  an  argument  that  the  colon  is  useless. 

NERVE  SUPPLY  OF  THE  COLON. 

The  nerves  governing  the  movements  of  the  colon  are  derived 
from  the  spinal  cord  and  the  plexuses  of  the  sympathetic.  The 
nerve  fibres  from  the  cord  pass  through  the  sympathetic  plexuses 
and  ganglia,  and  not  direct  from  the  cord,  with  the  exception  of  the 
rectum  and  lower  part  of  the  sigmoid  flexure,  which  receive  their 
fibres  from  the  first  three  sacral  nerves  via  the  hypogastric  plexus. 

There  are  also  fibres  from  the  splanchnics  and  from  the  vagi 
which  reach  the  colon,  as  there  is  distinct  evidence  of  the  move- 
ments of  the  colon  being  affected  by  central  nerve  impulses. 
Thus,  diarrhoea  and  a  desire  to  defaecate  is  undoubtedly  produced 
in  some  individuals  by  emotions  such  as  fear  or  nervousness, 
while  the  movements  of  the  colon  which  produce  borborygmi 
have  always  been  supposed  to  result  from  emotion,  the  expression 
"  the  bowels  of  compassion  "  having  its  origin  in  this  belief. 

The  movements  of  the  bowel  normally  result  from  reflex 
nerve  impulses,  originating  probably  in  Auerbach's  plexus  lying 
between  the  two  muscular  coats  of  the  colon,  and  the  initial 
impulse  originates  from  causes  within  the  bowel,  usually  either 
chemical  or  tactile.  Heat,  however,  may  cause  peristalsis, 
though  no  sensation  of  warmth  is  produced. 


OF    THE    COLON  15 

I  have  noted  that  the  introduction  of  warm  water  into  the 
colon  in  cases  of  appendicostomy  produces  immediate  and  some- 
times violent  peristalsis  much  more  readily  than  the  introduction 
of  cold  water.  The  same  fact  is  also  seen  where  a  draught  of  hot 
liquid  is  used  to  promote  the  action  of  the  bowels. 

Sensory  Nerves  of  the  Colon. — The  normal  mucous  mem- 
brane of  the  colon  does  not  possess  ordinary  tactile  sensation. 

Damage  or  injury  to  the  colon  does  not  cause  pain  directly, 
though  it  may  do  so  by  the  secondary  consequences  produced, 
such  as  peritonitis  or  peristalsis. 

I  have  studied  the  effect  of  injury  to  the  colon  in  animals,  and 
although  no  attempt  was  made  to  produce  pain,  as  the  animals 
were  under  full  ansesthesia,  it  was  possible,  by  observing  the 
effect  upon  the  blood-pressure,  to  notice  whether  any  effect 
upon  the  central  nervous  system  was  produced  through  afferent 
impulses  reaching  the  higher  centres  from  the  injured  area.  The 
blood-pressure  readily  responds  to  any  injury  to  sensory  nerve- 
endings,  and  therefore  this  method  gives  probably  just  as 
rehable  results  as  would  be  the  case  were  an  attempt  made  to 
produce  pain,  and  as  I  shall  be  able  to  show,  the  results  obtained 
correspond  with  observations  which  have  been  made  in  man. 

I  found  that  an  injury  such  as  crushing  or  hgaturing  the  wall 
of  the  colon  produced  no  effect  at  all,  providing  the  mesentery 
was  not  touched.  This  was  the  same  both  for  the  visceral 
peritoneum  and  the  mucous  membrane.  A  similar  injury  to  the 
parietal  peritoneum  or  to  the  mesentery  of  the  colon  did  produce 
an  effect  upon  the  blood-pressure. 

In  a  man  w^ho  has  had  a  colotomy  performed  it  is  possible  to 
confirm  this.  The  usual  practice  is  to  open  the  bowel  some  two 
days  after  the  operation,  and  when  this  is  done  it  is  noticeable 
that  cutting  the  bowel  wall  does  not  cause  pain  or  an}"  other 
sensation.  When  abdominal  operations  are  performed  under 
local  ansesthesia,  it  is  found  necessary  to  ansesthetize  the  parietal 
peritoneum  as  well  as  the  skin.  Directly  the  parietal  peritoneum 
is  touched,  if  it  has  not  been  previously  anaesthetized,  the  patient 
complains  of  pain  ;  but  the  colon  can  be  manipulated  or  operated 
upon  without  causing  pain  and  without  being  anaesthetized, 
providing  the  mesocolon  is  not  damaged  or  dragged  upon ;  either 
of  the  latter  will  cause  pain  or  uncomfortable  sensations. 

The  pain  produced  by  peritonitis  or  distention  must  be  attri- 
buted to  the  parietal  peritoneum  and  mesocolon. 


i6  NERVE    SUPPLY 

Violent  peristalsis  undoubtedly  produces  severe  pain,  and  this 
must  probably  be  attributed  to  the  bowel  wall  itself,  and  is  due 
to  violent  muscular  contraction. 

The  mucous  membrane  of  the  rectum  for  about  an  inch  above 
the  muco-cutaneous  junction  is  markedly  sensitive  to  tactile  or 
painful  stimuli.  Any  injury  to  the  mucous  membrane  in  this 
area  can  be  felt  and,  if  severe  enough,  will  cause  pain.  Ulcers 
in  this  situation  are  also  painful,  while  higher  up  they  do  not 
cause  pain  directly.  Injury  to  the  mucous  membrane  in  the 
higher  part  of  the  rectum  and  in  the  colon  does  not  cause  pain. 

From  the  consideration  of  these  facts  I  was  led  to  study  the 


SKIN 


B 


J'ig.  J  I. — Diagrammatic  section  of  a  colotoniy  opening.  The  control  obtained  will  be  better  in  A 
than  in  B,  owing  to  the  greater  amount  of  sensation  at  the  edge.  The  mucous  membrane  is 
shown  shaded. 


condition  of  sensation  at  the  opening  of  an  artificial  anus.  As 
has  already  been  mentioned,  no  sensation  is  present  in  the  mucous 
membrane  of  a  recent  artificial  anus  ;  but  I  found  that  after  a 
certain  time  the  mucous  membrane  at  the  edge  of  the  opening 
becomes  sensitive,  so  that  in  an  old  artificial  anus,  any  injury  to 
the  mucous  membrane  near  its  junction  with  the  skin  produces 
pain,  and  tactile  sensation  is  present. 

The  time  necessary  for  this  change  to  take  place  varies  con- 
siderably. It  does  not  usually  occur  under  six  months,  and 
often  not  till  much  later  ;  while  in  some  cases  it  does  not  appear 
to  occur  at  all. 


OF    THE    COLON  17 

The  following  are  instances  in  which  I  have  observed  this 
development  of  sensation  in  the  mucous  membrane  at  the  oriiice 
of  an  artificial  anus. 

In  the  case  of  a  woman  of  48,  who  had  had  her  rectum 
and  half  the  sigmoid  flexure  removed  for  cancer  by  abdomino- 
perineal excision,  the  centre  of  the  sigmoid  flexure  having  been 
brought  down  and  stitched  to  the  skin  at  the  anal  margin,  I 
found,  a  year  later,  that  she  could  feel  the  presence  of  fseces  in 
the  new  rectum,  and  they  caused  a  desire  to  evacuate.  If  the 
mucous  membrane  within  the  anal  canal  was  nipped  with  forceps, 
she  complained  of  pain. 

A  man,  aged  34,  who  had  had  a  similar  operation  performed, 
complained  of  pain  if  the  mucous  membrane  was  nipped,  and 
could  feel  the  presence  of  fseces  in  the  rectum  a  year  and  a  half 
after  the  operation. 

In  the  case  of  a  woman,  aged  33,  who  had  had  a  complete 
excision  of  the  rectum  performed  for  cancer,  and  the  sigmoid 
flexure  brought  down  and  stitched  to  the  skin,  I  found  that  she 
had  well-marked  sensation  a  year  later  in  the  mucous  membrane 
of  the  new  rectum. 

In  a  case  of  colotomy,  a  year  and  a  half  after  operation — man , 
aged  60 — the  patient  could  feel  the  presence  of  faeces  in  the  colon 
above  the  opening,  and  complained  of  pain  if  the  mucous  mem- 
brane near  the  orifice  was  pinched. 

In  a  man  of  33  with  a  colotomy,  the  same  condition  was 
noticed  nine  months  after  operation. 

PERISTALSIS. 

The  Effect  of  its  Contents  upon  Peristalsis  of  the 
Colon. — The  normal  stimulus  which  produces  peristalsis  in  the 
colon  arises  from  the  presence  of  something  within  the  bowel. 
Peristalsis  does  not  normally  occur  in  an  empty  colon,  and  the 
normal  stimulus  is  the  presence  of  a  certain  quantity  of  faecal 
material  within  it. 

There  is  good  reason  to  suppose  that  the  contraction  of  the 
unstriped  muscle  fibre  of  the  intestine  takes  place  normally 
only  as  the  result  of  local  stimulus.  Rapidly  increasing  tension, 
usually  distention,  is  another  normal  stimulus  to  contraction. 

Experimentally,  peristalsis  of  the  colon  may  be  produced 
artificially  in  several  ways.  The  introduction  of  irritant  fluids 
into  the  colon  will  induce  peristalsis,  but  in  my  experiments 


i8  PERISTALSIS 

their  effect  was  not  well  marked.  Such  substances  as  alcohol, 
solution  of  nicotine,  acids,  etc.,  were  introduced  through  a  small 
cannula,  and  the  effect  upon  the  colon  was  then  carefully  watched. 
Occasionally  slow  waves  of  peristalsis  occurred  and  continued 
for  a  short  time,  but  more  often  no  effect  resulted.  In  these 
experiments  the  animals  were  under  full  anaesthesia,  which 
tended  to  prevent  peristalsis  ;  but  this  fallacy  could  be  got  over 
to  some  extent  by  the  previous  injection  of  a  suitable  dose  of 
ergot  or  ernutin,  which  makes  the  colon  more  sensitive  to  any- 
thing which  will  cause  peristalsis. 

Large  doses  of  ergot  injected  subcutaneously  cause  consider- 
able and  prolonged  contraction  of  the  muscular  wall  of  the  colon,, 
and  this  may  be  used  as  a  means  of  combating  paralysis  of  the 
colon  in  cases  of  peritonitis  or  meteorism,  and  will  be  referred  to 
in  discussing  the  treatment  of  these  conditions. 

Experimentally,  by  far  the  readiest  means  of  producing 
peristalsis  in  the  colon  is  by  stretching  the  bowel  wall,  i.e.,  by 
distention.  In  my  experiments  this  was  done  by  distending  a 
portion  of  the  organ  either  with  air  or  with  warm  water.  The  air 
or  water  was  pumped  into  the  colon  with  a  lo-cc.  glass  syringe,, 
through  a  hypodermic  needle  pushed  slantwise  through  the  bowel 
wall. 

Distention  with  water  was  found  to  act  rather  better  than  air. 
As  soon  as  the  bowel  was  distended,  strong  peristaltic  waves, 
commenced  in  the  distended  area,  and  continued  until  the  dis- 
tention was  got  rid  of.  It  was  found  that  distention  in  this  way 
produced  peristalsis  more  readily  than  an}^  other  form  of  stimulus. 

A  local  injury  to  the  mucosa,  or  bowel  wall,  such  as  a  nip  with 
the  end  of  a  pair  of  forceps,  always  resulted  in  a  peristaltic 
contraction,  of  the  circular  fibres  chiefly.  The  contraction 
occurred  slowly,  did  not  commence  immediately,  and  took  from 
thirty  seconds  to  a  minute  before  it  was  complete,  when  a 
narrow  ring  of  contraction  had  occurred  narrowing  the  lumen 
to  about  one-sixth  of  its  normal  diameter. 

The  contraction  from  such  a  traumatic  stimulus  was  always 
local,  and  did  not  spread  in  either  direction  or  cause  waves  of 
peristalsis.  This  very  slow  response  to  traumatic  stimulus  of 
the  colon  is  different  from  what  occurs  in  the  small  bowel,  where 
the  resultant  contraction  is  the  same,  but  occurs  much  more 
rapidly. 

We  have  evidence  that  peristalsis  of  the  colon  can  be  induced 


PERISTALSIS  19 

by  chemicals  or  other  substances  introduced  into  the  bowel.  Sub- 
stances such  as  calomel,  castor  oil,  etc.,  introduced  into  the  colon 
through  an  appendicostomy  opening,  cause  well-marked  peri- 
stalsis ;  but  this  action  is  not  so  marked  as  if  given  by  the  mouth. 

Distention  with  water  introduced  through  an  appendicostomy 
opening  rapidly  produces  peristalsis,  the  fluid  being  evacuated 
at  the  anus  in  about  two  minutes,  thus  showing  that  very  active 
peristalsis  must  have  occurred. 

An  interesting  fact  I  have  noticed  is,  that  the  introduction  of 
a  solution  of  bile — fel  bovinum  of  the  British  Pharmacopoeia — 
into  the  caecum  through  an  appendicostomy  opening  has  a  mai'ked 
effect  in  stimulating  peristalsis  of  the  colon. 

Among  the  abnormal  causes  of  contraction  are  ; — 

1.  The  presence  of  a  foreign  body. 

2.  Inflammation  or  any  local  irritative  lesion. 

3.  Certain  drugs  or  foods,  notably  ergot. 

4.  Excess  of  carbonic  acid  in  the  blood  ;  this  is  well  seen  in 
the  contraction  occurring  in  the  intestine  in  asphyxial  conditions. 

Simple  complete  obstruction  of  the  bowel  lumen  does  not 
cause  peristalsis  providing  the  bowel  is  empty.  Accumulation 
of  faecal  material  above  the  obstruction,  however,  soon  occurs, 
and  as  a  result  of  this,  rather  than  of  the  obstruction  itself, 
violent  peristalsis  soon  ensues. 

If  the  obstruction  is  complete,  the  peristalsis  after  a  time 
ceases,  and  is  followed  by  paresis  of  the  gut  wall. 

If  the  obstruction  is  incomplete  or  intermittent,  hypertrophy 
and  increased  activity  of  the  muscular  wall  ultimately  develops. 

The  time  after  a  meal  at  which  food  commences  to  pass  from 
the  small  intestine  through  the  ileocaecal  valve  into  the  caecum 
is  difficult  to  ascertain,  and  probably  it  varies  considerably 
according  to  the  individual  and  the  nature  of  the  food. 

Sir  \Mlliam  Macewen  was  able  to  observe  the  passage  of  food 
through  the  ileocaecal  valve  in  a  patient,  the  anterior  wall  of 
whose  caecum  had  been  destroyed  by  an  explosion.  He  found 
that  in  one  or  two  hours  after  a  meal,  chyme  in  small 
quantities  began  to  pass  the  ileocaecal  valve. 

Dr.  Hertz,  who  made  careful  X-ray  observations  upon  human 
beings  who  had  previously  been  given  large  doses  of  bismuth, 
found  that  the  first  appearance  of  a  shadow  indicating  the 
presence  of  food  in  the  caecum  occurred  in  from  3^  to  5  hours 
after  a  meal ;  the  average  time  of  a  number  of  observations  being 


20  PERISTALSIS 

4f  hours.  This  is  considerabh'  longer  than  Mace  wen  found  : 
but  in  Hertz's  observations  it  is  obvious  that  no  shadow  would 
appear  till  a  fair  quantit}-  of  ch^^me  had  passed  into  the  caecum. 

Xo  movements  occur  in  the  empty  colon,  but  as  soon  as  the 
caecum  has  become  shghth'  distended,  slow  peristaltic  move- 
ments occur  in  the  caecum  and  colon  up  to  about  the  centre  of 
the  transverse  colon. 

At  first  these  movements  are  chiefi\"  antiperistaltic,  a  series 
of  waves  of  contraction,  one  following  the  other,  occurring  in  an 
antiperistaltic  direction  from  the  centre  of  the  transverse  colon 
backwards  towards  the  ileocaecal  valve.  The  presence  of  anti- 
peristalsis  in  the  colon  was  first  discovered  accidentally  by 
Jacobi.  Several  \\Titers  have  denied  that  antiperistalsis  occurs 
normalty,  but  as  I  shall  be  able  to  show,  it  is  quite  certain  that 
it  does.  Antiperistalsis  was  observed  by  Elliott  and  Barcla\-- 
Smith  in  cats  and  rats. 

Cannon  made  observations  with  the  X  rays  upon  cats  who  had 
been  given  large  doses  of  bismuth  in  their  food,  the  cats  having 
previously  been  given  nothing  for  tweh-e  hours,  and  the  bowels 
emptied  \\'ith  castor  oil.  He  confirmed  Jacobi's  observation. 
Antiperistaltic  waves  could  be  seen  to  start  near  the  end  of  the 
transverse  colon  and  pass  backwards  towards  the  caecum.  The 
first  period  of  antiperistalsis  lasted  from  two  to  eight  minutes, 
there  was  then  an  interval  of  from  fifteen  to  forty-five  minutes, 
when  the  antiperistaltic  waves  again  occurred. 

The  rate  of  contraction  observed  by  Cannon  was  about  eleven 
waves  in  two  minutes. 

Waves  of  segmentation  and  resegmentation  were  observed  by 
him  in  one  case  in  the  ascending  colon,  the  segmentation  being 
followed  by  antiperistalsis. 

Xo  leakage  past  the  ileocaecal  vah'e  in  the  reverse  direction  as 
the  result  of  antiperistalsis  was  observed. 

Dr.  Hertz,  in  a  series  of  similar  experiments  carried  out 
upon  healthy  men,  observed  the  same  phenomena  of  anti- 
peristalsis. 

I  have  done  several  experiments  upon  cats  with  the  object  of 
observing  the  movements  of  the  colon.  The  animals  were  kept 
anaesthetized  with  ether  in  a  warm  saline  tank,  and  the  colon 
exposed.  It  was  found  possible  in  this  wa}'  to  keep  the  bowel 
warm  and  active  for  an  hour  or  more,  while  at  the  same  time 
it   could  be    carefully   watched.      To  induce  peristalsis  warm 


PERISTALSIS 


21 


water  was  injected  into  the  colon  with  a  hypodermic  syringe 
until  sHght  distention  had  been  produced. 

The  antiperistaltic  waves  could  be  well  seen.     First,  a  ring  of 
contraction  occurred  in  the  transverse  colon  and  began  to  move 


\           / 

1            UhibiUcica              / 

\ 

hi 

r\ 

\ 

28                      \ 

/                    32 

F/i'.  12. — Series  of  colon  skiagrams  in  a  normal  individual.  The  numbers  represent  the  hours 
after  a  bismuth  breakfast  was  taken.  {Consti^)ation,  Dr.  Hertz  :  by  kind  permission  O.xf. 
Med.  Pub  A 

along  towards  the  caecum.  After  it  had  gone  about  an  inch, 
another  occurred  and  followed  it,  and  so  on,  so  that  a  long 
series  of  rings  of  contraction  could  be  observed  passing  towards 


22  PERISTALSIS 

the  ileocaecal  valve,  where  they  disappeared.  The  antiperistaltic 
movement  was  in  no  case  carried  into  the  ileum.  After  these 
antiperistaltic  waves  have  continued  for  some  minutes,  slow 
segmentation  occurs  in  the  colon.  Broad  bands  of  contraction 
occur  at  definite  intervals  along  the  colon,  and  remain  for  a 
minute  or  more,  then  the\-  relax,  and  others  take  their  place  at 
intermediate  positions. 


ist  stage 
2nd  stage 


3rd  stage 

Fig.  13. — Diagram  of  segmentation.     Notice  that  although  the  material  is  divided  and 
re-divided,  no  movement  takes  place  in  either  direction. 

This  segmentation  ma^'  be  followed  by  more  antiperistalsis, 
but  sooner  or  later  slow  peristaltic  waves  in  the  normal  direction 
occur,  tending  to  pass  the  contents  on  towards  the  descending 
colon.  The  object  of  the  antiperistaltic  wa^•es  is  evidently  to  mix 
up  the  contents  of  the  colon,  and  to  bring  them  intimatety  into 
contact  with  the  bowel  wall.  \A'hether  this  is  simply  to  allow 
of  as  much  moistiure  as  possible  being  removed  from  the  chyme, 
or  whether  it  indicates  digestive  absorption,  as  occurring  in  the 
Ccecum,  it  is  not  possible  to  say.  It  is  certain  that  fat  is  absorbed 
in  the  colon,  because  olive  oil  introduced  into  the  caecum  or 
rectum  is  absorbed  in  small  quantities  ;  and  in  1814,  Sir  Everard 
Home  pointed  out  that,  whereas  fat  could  be  extracted  from  the 
contents  of  the  caecum  in  ducks,  it  could  not  be  found  in  the 
contents  of  the  lower  bowel. 

Cannon  observed  that  if  enemas  were  administered  to  cats,  anti- 
peristalsis  occurred,  and  the  material  reached  the  caecum,  while 
if  the  enema  was  a  ver}"  large  one,  a  considerable  quantit}-^  was 
forced  backwards  through  the  ileocaecal  valve  into  the  ileum. 

In  no  instance  has  antiperistalsis  been  observed  in  the  ileum, 
and  it  probabty  does  not  normally  occur. 

The  peristaltic  waves  in  the  descending  colon  and  sigmoid 
are  slow  forward  movements,  and  antiperistalsis  is  not  observed 
here. 

Dr.  Hertz  found  that  it  took  about  4J  hours  for  food  to  pass 
from  the  caecum  to  the  splenic  flexure,  and  about  16  to  17  hours 


PERISTALSIS  23 

to  pass  from  there  to  the  lower  end  of  the  sigmoid  flexure.  He 
found  that  it  took  6  hours  to  pass  along  the  sigmoid  flexure. 
The  sigmoid  flexure  is  the  normal  reservoir  for  faecal  material 
before  dejection,  and  not,  as  is  often  supposed,  the  rectum.  The 
normal  function  of  the  rectum  is  only  as  an  expulsive  organ,  and 
the  presence  of  faeces  within  the  rectum  normally  gives  rise  to  an 
immediate  desire  to  defaecate.  In  animals  in  a  state  of  nature 
this  desire  is  immediately  followed  by  the  act  of  defaecation,  as 
is  also  often  the  case  in  paralyzed  persons.  The  necessities  of 
civihzation,  which  prevents  the  possibility  of  defaecation  taking' 
place  directly  the  desire  occurs,  has  necessitated  the  use  of  the 
sigmoid,  and  sometimes  of  the  rectum,  as  a  reservoir  for  faecal 
material  in  the  intervals  between  defaecation.  The  rectum  of  a 
normal  individual,  however,  does  not  contain  faeces  except  just 
before  and  during  the  act  of  defaecation.  I  have  examined  the 
rectum  of  a  great  number  of  patients,  and  in  the  large  majority 
of  healthy  individuals,  that  is  to  say  those  who  are  not  habitually 
constipated,  the  rectum  is  empty.  It  is  only  as  the  result  of 
habitual  constipation  and  carelessness  that  the  rectum  becomes 
a  reservoir  for  faecal  material. 

Dr.  Hertz,  who  carried  out  a  number  of  observations  with  the 
X  rays  upon  patients  suffering  from  chronic  constipation,  found 
that  the  cause  of  the  delay  in  the  movements  of  the  colon  varied 
considerably  in  different  cases.  Thus,  it  might  be  that  the 
fjecal  current  was  slower  in  all  parts  of  the  colon,  or  only  in  one 
part.  In  some  cases  it  was  only  in  the  sigmoid  and  rectum, 
while  in  others  it  was  in  the  transverse  colon,  the  passage  through 
the  sigmoid  and  rectum  taking  place  in  the  normal  time. 

Reversal  Experiments. — By  this  is  meant  resecting  a  portion 
of  the  large  bowel,  turning  it  round,  and  sewing  it  in  the  reverse 
position. 

These  experiments  have  been  done  by  numerous  observers, 
notably  by  Beers  and  Eggers,  Balance,  Edmunds,  Kelling,  and 
Hess,  the  object  being  to  ascertain  if  antiperistalsis  occurs  in 
the  colon.  The  best  proofs  of  this  now  well-established  fact 
are,  however,  the  X-ray  experiments  on  animals  and  human 
beings. 

In  those  cases  in  which,  after  union  had  taken  place,  the 
abdomen  of  the  animal  was  opened,  and  the  peristalsis  in  the 
reversed  loop  watched,  as  in  the  experiments  of  Beers  and  Eggers, 
peristaltic  waves  could  be  seen  to  occur  in  the  reversed  loop  in 


24  CONTENTS    OF 

the  same  direction  as  in  the  normal  colon,  the  peristaltic  wave 
passing  through  the  reversed  loop  to  the  bowel  below  it.  This 
was  observed  on  several  occasions  in  different  animals.  It  was 
almost  constantly  found  that  the  bowel  above  the  reversed  loop 
was  much  dilated,  often  for  a  considerable  distance,  and  con- 
tained foreign  bodies,  such  as  stones  or  faecal  concretions.  There 
was  also  considerable  hypertrophy  of  the  bowel  wall  above  the 
reversed  loop. 

These  experiments  show  that  the  reversed  loop  causes  an 
undoubted  obstruction  to  the  intestinal  flux,  but  that  the  flow  is 
re-estabhshed  and  becomes  in  time  more  or  less  normal. 

The  experiment  of  Murchison,  in  which  nearly  all  the  small  gut 
was  reversed,  and  yet  the  animal  defsecated  normally  and  lived 
three  weeks,  and  similar  experiments  of  Beers  and  Eggers  on 
the  small  and  large  gut,  go  much  further  to  prove  antiperistalsis. 

CONTENTS     OF     THE     COLON. 

Normally,  the  contents  of  the  csecum  and  ascending  colon  are 
liquid  or  semi-fluid,  while  those  of  the  sigmoid  flexure  are  solid. 

Mucus. — Mucus  is  a  normal  content  of  the  colon,  and  is  freeh^ 
secreted  by  its  walls.  Macewen  observed  the  secretion  of  mucus 
by  the  walls  of  the  caecum,  and  found  that  it  began  just  before 
the  chyme  passed  from  the  ileum  into  the  caecum. 

A  considerable  amount  of  mucus  is  normally  present  in  the 
fjeces,  but  not  in  sufficient  quantities  to  be  obvious.  In  certain 
diseased  states,  however,  an  abnormal  amount  of  secretion 
occurs.  This  is  notably  the  case  in  chronic  mucous  and  mem- 
branous colitis,  in  which  very  large  quantities  of  mucus  are 
passed  "  per  anum."  In  membranous  colitis,  the  mucus  ma}' 
be  in  the  form  of  complete  casts  of  the  bowel.  The  walls  of 
these  tubular  casts,  which  may  be  a  foot  or  more  in  length  and 
conform  to  the  shape  of  the  colon,  are  laminated,  and  consist  of 
mucus  and  epithelial  casts. 

Microscopicalty,  the}^  are  structureless  ;  and,  chemically,  they 
consist  of  mucus. 

Much  importance  has  been  attached  to  these  casts,  and  their 
presence  in  the  stools  has  been  attributed  to  a  disease  called 
membranous  colitis.  The  casts  are  simply  the  normal  mucus  of 
the  colon  secreted  in  abnormal  quantities  which,  for  some  reason, 
has  remained  on  the  surface  of  the  mucosa  and  become  solidified 
there,  so  that  a  complete  cast  of  the  bowel  in  mucus  has  formed 


THE    COLON  25 

which,  sooner  or  later,  has  become  separated  and  dejected  in  its 
entirety. 

Excessive  secretion  of  mucus  will  result  from  any  irritative 
condition  of  the  colon,  such  as  chronic  inflammation,  cancer, 
polypus,  intussusception,  etc. 

There  does  not  seem  to  be  any  sound  reason  for  attaching 
special  significance  to  the  form  in  which  the  mucus  is  present  in 
the  stools. 

Fat  in  the  Stools. — A  certain  amount  of  fat  is  normally 
present  in  the  stools  in  most  individuals.  The  amount  which 
is  absorbed  during  the  passage  of  the  food  through  the  intestine 
is  very  limited,  and  any  excess  of  fat  in  the  diet  will,  in  almost 
all  cases,  lead  to  an  excess  of  fat  in  the  stools. 

If  mineral  fats  are  included  in  the  diet,  such  as  petroleum  or 
vaseline,  they  are  not  absorbed  at  all,  and  re-appear  again  in  the 
stools. 

Most  animal  and  mineral  fats  are  liquid  at  body  temperature, 
and,  consequently,  if  there  be  an  excess  of  fat  in  the  stools,  the 
latter  will  be  semi-solid  or  liquid,  and  this  fact  may  be  made  use 
of  in  the  treatment  of  some  varieties  of  constipation. 

It  also  affords  us  a  most  valuable  method  of  keeping  the  stools 
liquid  and  soft  after  an  operation  in  which  the  colon  has  been 
resected,  or  an  anastomosis  has  been  performed,  and  we  wish  to 
avoid  any  possibility  of  strain  due  to  solid  faecal  material  being 
thrown  upon  a  recent  wound  in  the  bowel  wall. 

Intestinal  Sand. — Intestinal  sand  is  occasionally  present  in 
the  feeces  as  an  abnormal  constituent,  and  may  cause  bleeding 
and  severe  pain,  owing  to  the  traumatism  of  the  mucosa  involved 
in  its  passage  along  the  intestinal  tract.  The  origin  of  this  sand 
has  not  been  ascertained,  but  it  closely  corresponds  to  the  uric 
acid  gravel  passed  in  urine.  When  first  passed  it  is  red  in  colour, 
but  soon  becomes  black  when  kept  in  contact  with  the  air.  Its 
composition  is  as  follows  : — 

Organic  matter        30-70  per  cent. 

'Calcium  phosphate  98  per  cent. 
Magnesium  | 

^  1  ■  1   ,       f  A  trace 

Calcmm  oxalate 

.Silica  -' 

I  had  one  patient  who  passed  as   much   as   two   ounces  in 

twenty-four  hours  ;   but  usually  there  is  much  less  than  this. 


Inorganic  matter 


26  CONTENTS    OF 

Other  Abnormal  Contents. — In  cases  of  intestinal  obstruc- 
tion, the  contents  of  the  colon  become  altered.  This  is  probably 
due  to  two  causes  : — 

1.  Abnormal  retention  of  the  contents  allows  excessive  and 
abnormal  fermentation  to  occur. 

2.  The  normal  absorption  and  secretion  of  the  bowel-wall 
being  arrested,  abnormal  substances  are  able  to  form. 

Nesbitt,  who  produced  intestinal  obstruction  artificially  in 
dogs,  found  that  highly  poisonous  substances  were  formed  in  the 
obstructed  loops  of  bowel.  The  most  notable  of  these  were 
neurin  and  cholin,  both  of  which  are  not  present  in  the  normal 
bowel  contents. 

These  substances  are  of  the  nature  of  what  are  known  as  toxins, 
and  it  is  the  absorption  of  such  toxins  through  the  damaged 
bowel-wall  and  their  entrj^  into  the  blood-stream  which  is  one  of 
the  principal  causes  of  death  in  cases  of  intestinal  obstruction. 

Some  experiments  carried  out  by  Clairmont  and  Ranzi  prove 
the  extremely  poisonous  nature  of  these  toxins.  They  found 
that,  while  the  filtrate  from  the  contents  of  a  normal  intestine 
produced  no  harmful  effects  when  injected  into  animals,  a 
similar  filtrate  prepared  from  the  contents  of  a  loop  of  strangu- 
lated bowel  produced  serious,  and  often  fatal,  results  when 
injected. 

The  normal  faeces  are  solid  or  semi-solid,  depending  on  the 
dietary,  and  to  some  extent  the  personal  habits,  of  the  individual. 

Fluid  faeces  are  always  abnormal,  and  the  result  of  some 
disturbance  of  the  digesti\'e  functions,  or  of  some  pathological 
process. 

Diarrhoea  ma}^  be  of  two  kinds  :  (a)  Lienteric  diarrhoea,  in 
which  the  fluidity  is  due  to  insufficient  absorption  of  the  fluids 
ingested  ;   {b)  Excessive  secretion  by  the  walls  of  the  colon. 

Lienteric  Diarrhoea  may  result  from  increased  activity  of  the 
muscular  wall  of  the  colon,  so  that  the  contents,  which  are  fluid 
on  reaching  the  caecum,  are  hurried  on  before  there  has  been 
time  for  the  fluid  constituents  to  be  absorbed  ;  or  it  maj^  be  due 
to  a  loss  of  the  normal  absorptive  power  of  the  mucosa. 

The  commonest  pathological  cause  of  diarrhoea  is  certainly 
Excessive  Secretion  b\^  the  mucosa  of  the  colon,  due  to  irritative 
or  inflammatory  conditions.  But  insufficient  absorption  is  also 
present  in  most  cases. 

The  colour  of  the  faeces  is  almost  entirely  dependent  upon  the 


THE    COLON  27 

constituents  of  the  food,  or  to  the  presence  of  bile  or  blood  in  the 
stools. 

The  normal  colour  of  the  faeces  is  due  to  bile.  Light-coloured 
or  yellow  stools  may  result  from  less  bile  than  normal,  or  from 
excess  of  fats. 

A  normal  stool  is  slightly  acid.     The  acidity  is  often  increased 

when  there   is  inflammation   or  increased   fermentation  in  the 

colon. 

REFERENCES. 

C.^xxox. — Amer.  Jour,  of  Phys.  Jan.  1904. 

Elliott  and  Barclay  Smith. — Jour,  of  Phys.  1904,  p.  272. 

Hertz. — Brit.  Med.  Jour.  1908,  i.  p.  191. 

Jacobi. — Arch.  f.  Exp.  Path.  1890. 

Macewen. — Lancet,   1904,  ii.  997. 


28 


Chapter    III 

MORBID    PHYSIOLOGY    OF    THE    COLON 

THE  RESULTS  OF  OCCLUSION  OF  THE  WHOLE  OR 
PART  OF  THE  COLON. 

In  many  operations  upon  the  colon  in  which  an  artificial  anus 
is  established  or  a  short-circuiting  operation  is  performed,  some 
portion  of  the  colon  is  left  as  a  blind  pouch  or,  in  a  few  cases,  is 
entirely  occluded.  In  the  operation  of  ileosigmoidostomy,  the 
entire  colon  is  short-circuited  or  is  disconnected  from  the  ileum. 
There  have  been  many  conflicting  opinions  and  much  contra- 
dictory evidence  as  to  the  results  that  occur  in  such  cases,  and 
the  safety  to  the  patient  or  otherwise  in  leaving  such  conditions. 
I  propose  here  to  attempt  to  consider  what  changes  take  place 
in  the  colon  as  the  result  of  such  operations. 

Senn  was  one  of  the  first  to  investigate  this  subject  experi- 
mentally. He  found  that  if  a  portion  of  the  bowel  was  entirely 
occluded  and  its  ends  closed,  it  became  in  time  distended,  and  a 
source  of  danger  from  the  accumulation  of  secretion  within  it. 

Druebert  performed  iliosigmoidostomy  upon  dogs  and  found 
that,  for  some  weeks  after  operation,  the  stools  were  fluid  and 
the  excluded  colon  remained  empty,  but  after  a  time  the  stools 
became  more  solid,  and  feecal  material  began  to  pass  backwards 
into  the  excluded  colon  and  to  accumulate  there. 

Koste,  in  a  case  in  which  he  had  excised  the  cgecum  for  hyper- 
plastic tuberculosis  and  implanted  the  end  of  the  ileum  into  the 
sigmoid  flexure,  narrowed  the  colon  just  above  the  point  at 
which  the  ileum  joined  it  by  means  of  a  ligature,  with  the  object 
of  preventing  regurgitation  of  fsecal  material  into  the  colon. 
In  this  case  there  was  a  fistula  communicating  with  the  blind 
end  of  the  ascending  colon,  and  for  six  and  a  half  months  after 
operation  no  faecal  material  escaped  from  the  fistula.  After  this, 
however,  faeces  began  to  come  away  from  the  fistula.  Koste  later 
divided  the  splenic  flexure  and  closed  the  ends.  After  this,  the 
discharge  from  the  fistula  stopped. 


OCCLUSION    OF    THE    COLON  29 

Wiessinger  found  that,  out  of  four  cases  in  which  a  portion  of 
the  colon  had  been  entirely  occluded,  rupture  of  the  occluded 
portion  or  the  formation  of  a  fistula  occurred  in  three.  Brown 
occluded  a  portion  of  the  colon  in  dogs,  and  found  that,  in  three 
to  four  weeks,  the  occluded  portion  was  much  distended  with 
faecal-like  material  ;  in  all  cases  the  distention  was  greatest 
at  the  distal  end.  Reichel  concluded  from  experiments  on 
animals  that  accumulation  in  an  occluded  loop  may  or  may  not 
occur.  Obalinski  also  concluded  from  experiment  that  total 
occlusion  is  not  followed  by  serious  consequences  in  the  colon, 
but  is  dangerous  in  the  small  intestine. 

In  a  case  of  colotomy,  the  bowel  below  the  artificial  opening 
becomes  in  course  of  time  considerably  atrophied.  It  loses  its 
pouches,  and  becomes  a  smooth  and  comparatively  narrow 
tube. 

I  have  seen  a  case  in  which  the  end  of  the  sigmoid  flexure  was 
closed  and  an  artificial  anus  estabhshed  some  6  inches  higher 
up,  the  blind  pouch  of  pelvic  colon  being  left  in  the  abdomen. 
The  artificial  anus  did  not  allow  of  istces  getting  into  the  bhnd 
end,  but,  in  the  course  of  about  a  year,  serious  accumulation 
occurred  in  the  blind  pouch,  causing  ulceration  and  a  fistula. 

Lance  collected  76  cases  of  bilateral  exclusion.  In  8  cases 
in  which  the  operation  was  done  for  faecal  fistula,  all  recovered. 
In  68  cases  where  the  operation  was  done  for  other  conditions, 
no  death  or  bad  result  followed.  As  a  method  of  closing  a  faecal 
fistula,  he  found  bilateral  exclusion  succeeded  in  all  cases 
except  where  malignant  disease  was  present. 

The  Effects  of  Leaving  Blind  or  Occluded  Portions  of  the 
Colon  after  Resection. — If,  after  resection  of  any  portion  of 
the  colon,  an  anastomosis  be  made  in  such  a  way  as  to  leave  a 
bhnd  pouch,  as  for  instance,  if  the  end  of  the  descending  colon 
is  closed  and  the  ascending  or  transverse  colon  anastomosed 
to  the  sigmoid  flexure,  accumulation  of  faecal  material  in 
the  bhnd  pouch  will  occur.  If  the  bhnd  pouch  is  a  distal  one, 
i.e.,  if  normal  peristalsis  passes  into  it,  the  accumulation  will  be 
more  serious  and  occur  more  rapidly  than  if  it  be  proximal, 
i.e.,  if  normal  peristalsis  passes  from  it  (see  Fig.  14).  But  even 
in  the  latter  case,  owing  probably  to  the  fact  that  antiperistalsis 
occurs  normally  in  the  colon,  at  any  rate  as  far  as  the  upper 
end  of  the  descending  colon,  considerable  accumulation  will 
eventually  occur,  and,  in  course  of  time,  perforation  of  the  end 


30  OCCLUSION    OF 

of  the  blind  pouch  from  stercoral  ulceration,  and  thfe  conse- 
quent formation  of  an  abscess,  will  take  place. 

This  also  occurs  when  the  end  of  the  divided  ileum  is  implanted 
into  the  sigmoid  flexure,  as  in  one  method  of  performing  ileo- 
sigmoidostomy. 

Mr.  Arbuthnot  Lane,  who  has  performed  this  operation  manj^ 
times,  found  that  after  a  time  accumulation  of  faeces  and  gas 
occurred  in  the  excluded  colon  and  caused  unpleasant  symptoms 
which  necessitated  its  removal.  He  found  that  even  if  onty  the 
excluded  descending  colon  was  left,  accumulation  in  it  still 
occurred  after  a  time,  and  it  had  to  be  resected. 

If  the  colon  is  entirely  excluded  by  the  formation  of  an  arti- 
ficial anus  in  the  caecum,  the  patient  will  lose  a  great  quantit}'  of 


Pig,  14.— Occlusion  of  the  colon  by  anastomosis  with  A  a  distal,  and   B  a  proximal  blind  pouch. 

fluid  which,  under  normal  circumstances,  would  be  returned 
into  the  circulation.  When  the  colon  is  excluded  by  ileo- 
sigmoidostomy,  this  loss  of  fluid  is  not  so  marked,  owing  to  the 
action  of  the  sigmoid  in  absorbing  fluids  from  the  excreta. 

Mr.  Monier  WilHams*  has  recorded  a  very  instructive  case  in 
this  connection.  The  patient  was  a  man ,  aged  52,  with  ulcerative 
cohtis.  An  artificial  anus  was  made  into  the  ascending  colon 
close  to  the  caecum,  and  a  special  apparatus  was  fitted  which 
prevented  any  of  the  fsecal  material  passing  into  the  colon. 

The  patient  improved  greatly  in  health  until  about  a  year  and 
a  half  after  the  operation,  when  he  began  rapidly  to  lose  ground 
and  became  emaciated.  Half  a  pint  of  normal  sahne  solution 
was  then  put  into  the  colon  daily,  and  he  began  to  improve 


*  Brit.  Med.   Jour.   1906,  i.  787. 


THE    COLON  31 

again.  Three  months  later,  however,  he  developed  purpura 
haemorrhagica,  and  bled  profuseh'.  There  were  several  similar 
attacks,  until  the  plan  was  adopted  of  removing  the  plug  in  the 
artificial  anus  at  night  and  allowing  the  faeces  to  pass  into  the 
colon,  replacing  the  plug  during  the  day.  After  this  the  patient 
regained  perfect  health  and  remained  well  for  three  years. 

Arbuthnot  Lane  has  found,  after  resection  of  the  entire 
colon,  that  the  patients  suffer  severely  from  vomiting,  which 
in  several  cases  has  threatened  to  end  fatally ;  this  can  be 
prevented  b}^  subcutaneous  infusion  of  water. 

It  is,  I  think,  evident  that  the  loss  of  body  fluids  resulting 
from  total  exclusion  or  excision  of  the  colon  may  seriously 
interfere  with  health,  and  that  this  loss  cannot  be  entirely 
compensated  by  an  increased  intake  of  fluid  by  the  mouth. 
Further,  loss  of  health  from  that  cause  may  not  be  evident  for 
a  long  period  after  operation.  It  would  seem  that  it  is  not  the 
loss  of  fluid  alone,  but  of  some  other  constituent  of  the  intestinal 
contents  normally  absorbed  or  re-absorbed  by  the  colon,  which 
interferes  with  the  patient's  health.  In  Monier  Williams's  case, 
the  patient  could  not  be  kept  in  good  health  by  putting  water 
into  the  colon,  but  it  was  necessary  to  allow  the  faeces  to  pass  in. 

Total  excision  of  the  colon  has  been  performed  several  times 
by  Lane  and  others,  and  its  loss  has  been  proved  to  be  not 
incompatible  with  life  or  with  good  health  ;  but  we  have  at 
present  no  record  of  a  case  showing  the  condition  of  the  patient 
two  or  three  years  after  such  an  operation. 

We  may,  however,  conclude  from  the  foregoing  that  occlusion 
of  the  colon,  either  partial  or  total,  is  a  condition  which  in  most 
cases  is  not  compatible  with  the  permanent  maintenance  of 
good  health.  Accumulation  of  faeces  occurs  sooner  or  later  in 
the  occluded  loop  and  causes  trouble  which,  if  unreHeved,  may 
give  rise  to  abscess  or  perforation,  and  certainly  to  auto- 
intoxication. 

If  the  occluded  loop  is  distal  to  the  anastomosis,  as  in  Fzg.  14.4, 
accumulation  will  occur  rapidly,  and  if  proximal,  as  in  Fig.  14  B, 
it  will  occur  more  slowly,  but  it  will  nevertheless  almost  certainly 
take  place.  Total  exclusion  of  a  portion  of  the  colon  is  not 
compatible  with  permanent  good  health,  unless  a  fistula  is 
left  communicating  with  the  excluded  portion.  If  that  portion 
of  the  colon  is  left  without  an  external  fistulous  communica- 
tion, an  abscess  will  eventually  form. 


32  OCCLUSION     OF 

Total  excision  of  the  colon  is  certainly  compatible  with  life  ; 
but  there  is  not  at  present  sufficient  evidence  to  show  whether 
or  not  it  is  consistent  with  permanent  good  health. 

Acute  Dilatation  of  the  Colon  :  Meteorism- — Acute  dilata- 
tion of  the  colon  does  not  occur  apparent^  as  a  primary 
condition,  but  only  as  a  complication  of  other  diseased  states  of 
the  bowel.  It  may  occur  from  interference  with  the  blood- 
supply  of  the  colon,  as  in  cases  of  thrombosis  of  the  colic  veins, 
or  volvulus  of  the  sigmoid  flexure  ;  from  inflammation  of  the 
peritoneum,  as  in  acute  peritonitis  ;  and  from  obstruction  of 
the  lumen  of  the  bowel. 

In  all  cases  of  thrombosis  of  the  colic  veins,  acute  dilatation  of 
the  affected  portion  of  the  colon  is  a  marked  feature ;  the  dilata- 
tion in  such  cases  is  not  always  confined  to  the  portion  of  colon 
the  blood-supply  of  which  has  been  injured,  for  complete  obstruc- 
tion to  the  passage  of  faecal  material,  and  even  gas,  is  caused 
by  the  damaged  blood-supply,  and  it  is  usualty  found  that  the 
bowel,  for  some  distance  above  the  affected  area,  is  also  dilated. 

The  most  extreme  cases  of  acute  dilatation  or  meteorism  of 
the  colon  are  those  in  which  the  blood-suppty  is  interfered  with, 
when  an  extraordinary  degree  of  distention  of  the  colon  may 
occur  in  a  few  hours.  In  cases  of  volvulus  of  the  sigmoid 
flexure,  in  which  the  mesosigmoid  is  so  twisted  as  to  arrest  the 
blood-supply  of  the  sigmoid,  great  distention  of  the  affected 
portion  of  bowel  very  rapidly  occurs.  Interference  with  the 
venous  return  of  blood  from  the  bowel,  the  arterial  supply 
remaining  intact,  would  appear  to  cause  a  greater  degree  of 
distention  than  total  arrest  of  all  the  circulation  in  the  colon. 
It  is  very  difficult  to  be  certain  of  this  point  on  pure  clinical 
evidence,  since  it  is  usually  impossible  to  be  certain  that  the 
veins  alone  are  blocked  in  any  case  of  volvulus  or  other  form  of 
strangulation.  If  we  try  to  compare  the  cases  of  thrombosis 
of  the  colic  veins  with  cases  of  pure  arterial  thrombosis,  the 
cases  of  the  latter  condition  are  so  rare  that  no  useful  evidence 
can  be  brought  forward.  It  is  certain,  however,  that  dilatation 
of  the  colon  occurs  in  both  conditions. 

Experimental  evidence,  however,  proves  that  venous  stasis  is 
a  more  potent  factor  in  causing  acute  meteorism  of  the  colon 
than  is  arterial  stasis  only.  I  have  performed  a  number  of 
experiments  with  the  object  of  ascertaining  the  causes  of  dilata- 
tion, with  the  following  results  : — 


THE     COLON  33 

If  an  animal's  abdomen  is  opened  and  the  main  veins  of  a 
section  of  the  colon  are  ligatured  or  clamped,  so  that  the  venous 
flow  from  that  portion  of  the  colon  is  entirely  arrested,  and  the 
abdomen  is  again  closed,  it  will  be  found  in  an  hour  or  two,  if  the 
abdomen  be  reopened,  that  this  portion  of  the  colon  has  become 
considerably  dilated.  The  affected  portion  of  colon  is  found  to 
be  dusky  in  colour,  and  much  distended  with  gas.  If  some  of 
the  gas  is  removed  with  a  clean  glass  sjTinge  and  tested,  it  is 
found  to  be  principally  CO,,. 

The  dilatation  occurs  very  rapidly  in  spite  of  the  fact  that 
the  bowel  is  open  at  both  ends,  as  a  marked  degree  of  dilatation 
was  present  in  an  hour  and  a  half  after  the  veins  had  been  tied. 
Clamping  or  ligature  of  the  arteries  going  to  a  similar  portion 
of  the  colon,  produced  practically  no  dilatation  in  the  period 
covered  by  the  experiment. 

It  is  an  easily  observed  and  well  known  fact,  that  portions  of 
bowel  enclosed  within  the  grasp  of  intestinal  clamps  during 
operations  become  markedly  dilated  with  gas,  even  in  the  short 
period  obtaining  during  an  operation  such  as  lateral  anastomosis 
between  portions  of  the  colon,  and  in  gastrojejunostomy. 

The  CO.,  w^hich  accumulates  in  the  bowel  and  causes  the 
dilatation,  results  from  the  fermentative  processes  occurring  in 
the  intestinal  contents  ;  the  gases  (as  CO^  is  probably  not  the 
only  gas  present)  are  normally  absorbed  by  the  blood,  and 
carried  away  in  the  venous  blood-stream  under  normal  con- 
ditions ;  but  when  the  venous  stream  has  been  arrested,  they 
accumulate  and  distend  the  bowel.  When  performing  the 
experiments  already  mentioned,  I  found  that  if,  before  ligating 
the  veins,  the  colon  was  first  washed  out,  so  that  its  interior  was 
rendered  as  clean  as  possible,  no  distention  with  gas  occurred. 

In  performing  this  experiment,  two  openings  were  made  at 
opposite  ends  of  a  length  of  colon,  and  through  them  the  bowel 
w^as  washed  clean  with  normal  salt  solution ;  the  colon  was  then 
clamped  above  and  below,  so  that  the  cleaned  portion  was  quite 
isolated,  and  the  openings  were  then  closed.  The  veins  were 
next  all  ligated  without  injury  to  the  arterial  supply,  and  the 
bowel  was  returned  into  the  abdomen.  At  the  end  of  an  hour  the 
colon  between  the  clamps  was  still  quite  collapsed,  and  there 
was  no  evidence  of  distention.  These  experiments  were  repeated 
several  times,  always  with  the  same  result.  We  are  therefore, 
I  think,  justified  in  assuming  that  the  gas  causing  the  distention 

3 


34  OCCLUSION    OF 

results  primarily  from  fermentative  processes  in  the  faeces,  and 
that  normally  this  gas  is  absorbed  by  the  blood  or  carried  away 
in  the  venous  blood.  The  distention  is  therefore  a  condition 
which  would  normally  occur,  but  is  kept  in  check  by  the  blood- 
stream under  ordinary  conditions  of  health. 

These  experiments  also  point  out  the  way  in  which  meteorism 
may  be  prevented.  It  is  obvious  that  this  may  be  done 
either  by  emptying  the  colon,  or  by  introducing  some  substance 
which  will  prevent  or  delay  fermentation. 

In  order  to  render  these  experiments  complete,  I  thought 
it  necessary  to  prove  that  the  normal  mucous  membrane  of 
the  colon  could  absorb  C0._,.  This  was  done  as  follows  :  The 
ileum  of  a  cat  was  ligatured  just  above  the  ileocaecal  valve,  and 
the  middle  of  the  colon  was  similarly  ligatured.  The  upper 
part  of  the  colon  which  was  thus  completely  closed  was  then 
distended  with  CO  2  by  means  of  a  fine  hypodermic  needle 
attached  to  a  gas-bag,  the  needle  being  passed  obliquely 
through  the  bowel  wall.  The  abdomen  was  then  closed.  At 
the  end  of  one  hour  and  forty  minutes  the  occluded  portion 
of  colon  was  examined,  when  it  was  found  that  most  of  the 
CO 2  had  been  absorbed  and  the  bowel  was  partially  collapsed. 
As  the  gas  could  only  have  escaped  by  passing  through  the 
bowel  wall,  I  think  we  may  assume  that  it  had  been  carried 
away  in  the  blood-stream. 

Apart  from  interference  with  the  venous  drainage,  however, 
acute  dilatation  or  meteorism  of  the  colon  also  occurs  in  cases 
of  acute  peritonitis.  The  most  marked  dilatation  in  such  cases 
occurs  in  the  small  bowel,  but  the  colon  also  usually  shares  in 
the  dilatation,  though  to  a  less  marked  degree.  This  is  no  doubt 
partly  due  to  the  fact  that  the  greater  area  and  more  central 
position  of  the  small  bowel  results  in  its  peritoneal  coat  being 
more  acutely  inflamed  than  that  of  the  colon  in  most  cases  of 
general  peritonitis. 

The  cause  of  dilatation  in  peritonitis  is  not  so  obvious  as  in 
the  conditions  previously  considered,  but  it  would  seem  probable 
that  it  is  due  to  some  interference  with  the  absorbing  power  of 
the  mucous  membrane.  The  paralysis  of  the  bowel  musculature 
which  accompanies  acute  peritonitis  will  also  obviously  be  an 
important  factor,  because  it  prevents  the  faecal  contents  being 
passed  on,  and  enables  the  latter  to  accumulate  and  excessive 
fermentation  to  occur  ;    but  arrest  of  peristalsis  wiU  not  alone 


THE    COLON  35 

account  for  the  meteorism  of  peritonitis.  When  once  any 
marked  degree  of  meteorism  has  occurred,  a  "  vicious  circle  "  is 
estabhshed  :  the  extreme  dilatation  of  the  colon  tends  to  produce 
kinks  and  angles  in  the  bowel,  which  cause  obstruction  to  the 
lumen  ;  moreover,  the  stretching  of  the  bowel  wall  further 
paralyzes  the  muscular  walls  in  the  same  way  that  stretching 
the  anal  sphincter  paralyzes  that  muscle.  It  is  owing  to  the 
estabhshment  of  this  "  vicious  circle  "  that  the  condition  of 
meteorism,  once  well  established,  is  so  extremely  difficult  to 
deal  with  successfully. 

Post-operative  Meteorism. — There  has  at  different  times 
been  much  discussion  as  to  whether  post-operative  meteorism 
occurs  at  all,  apart  from  some  degree  of  peritonitis.  It  has  been 
noticed  that  it  is  more  liable  to  happen  in  cases  where  morphia 
has  been  administered,  and  it  has  been  supposed  that  the 
morphia  was  the  cause  of  it.  It  occurs,  however,  in  cases 
w'here  no  morphia  has  been  given,  while  it  does  not  take 
place  after  abdominal  operations  performed  under  the  most 
careful  modern  surgical  technique,  where  no  cause  for  infec- 
tion exists,  that  is,  where  the  bowel  has  not  been  opened. 
I  have  ne\-er  seen  it,  nor  been  able  to  find  an  instance  of  it, 
except  in  cases  where  there  were  obvious  possibilities  of  some 
infection.  Also  it  has  become  decidedly  less  common  in  the 
last  few  years,  since  more  careful  aseptic  methods  have  pre- 
vailed. 

These  facts,  and  its  close  resemblance  to  meteorism  occurring 
as  a  symptom  of  general  peritonitis,  make  it  almost  certain  that 
it  is  the  result  of  microbic  infection  of  the  peritoneum.  It 
usually  occurs  within  forty-eight  hours  after  an  operation, 
accompanied  by  pain,  raised  temperature,  and  other  signs 
of  peritoneal  infection,  and  in  those  cases  where  it  has  proved 
fatal,  signs  of  peritonitis  are  present. 

In  acute  dilatation  of  the  colon,  the  walls  of  the  bowel  are 
thinned  and  stretched  so  that  in  some  cases  they  may  be  almost 
transparent.  The  tension  within  the  bowel  may  be  considerable, 
and  it  has  happened,  on  opening  the  abdomen  for  the  purpose  of 
relieving  an  obstruction,  that  the  visceral  peritoneum  covering 
the  distended  bowel  has  split  directh'  the  support  of  the 
abdominal  wall  has  been  removed.  It  is  advisable,  when  opera- 
ting in  cases  of  well-marked  meteorism,  to  make  as  small  an 
abdominal  incision  as  possible,  in  order  to  avoid  this  danger. 


36  OCCLUSION    OF    THE    COLON 

\Mien  the  colon  becomes  dilated  above  a  stricture  or  other 
obstruction  of  the  bowel  lumen,  the  distention  occurs  much  more 
slowly  than  in  those  cases  where  the  blood-supply  of  the  colon 
has  been  damaged,  or  where  there  is  peritonitis. 

It  is  certain  that  the  only  satisfactory  method  of  dealing  with 
meteorism  is  to  empty  the  colon  of  its  contents  and  thus  prevent 
the  fermentation  which  causes  it.  This  may  be  done  by  opening 
a  distended  coil  and  emptying  the  contents  by  some  such  method 
as  that  invented  by  Moynihan,  with  a  long  tube  on  to  which 
successive  coils  can  be  pulled. 


37 


Chapter    IV. 

BACTERIOLOGY    OF    THE    COLON. 

The  number  of  micro-organisms  present  in  the  intestinal  contents 
of  man  and  the  raammaha  is  enormous  ;  it  has  been  estimated 
that  there  are  on  an  average  one  hundred  and  twenty-six  bilhons 
for  the  daily  human  excreta. 

The  fact  that  the  digestive  tract  is  so  rich  in  bacteria  has  led 
many  ph\-siologists  to  the  belief  that  they  are  essential  to  the 
well-being  of  the  host.  Pasteur  expressed  this  view,  and  other 
observers,  such  as  Schottelius,  Madame  Metchnikoff,  and  Moro, 
have  agreed  with  him,  and  experiments  in  which  chickens, 
tadpoles,  and  turtle  larvae  have  been  fed  on  sterile  food,  with 
the  result  that  their  development  was  retarded,  are  brought 
forward  in  support  of  this  view. 

These  experiments  are  not,  however,  conclusive  ;  on  the 
other  hand,  Nuttall  and  Thierpelder  reared  guinea-pigs, 
delivered  by  Caesarean  section,  on  sterile  food,  and  the  animals 
lived  and  increased  in  weight.  More  important  are  the  obser- 
vations of  Levin,  that  many  of  the  animals  in  the  Arctic  regions 
have  no  bacteria  in  their  digestive  tract.  He  investigated  the 
intestinal  contents  of  Arctic  animals  at  Spitzbergen,  and  found 
that,  in  most  instances,  in  white  bears,  seals,  reindeer,  eider- 
ducks,  and  penguins,  the  digestive  tracts  were  entirely  sterile. 
This,  I  think,  proves  conclusively  that  bacteria  in  the  intestinal 
tract  are  not  in  any  way  necessary  to  life,  and  it  is  probably 
correct  to  look  upon  their  presence  rather  as  a  necessary  feature 
of  residence  in  warm  or  temperate  climates,  and,  like  dirt  and 
bacteria  upon  the  surface  of  the  body,  as  being  to  a  large  extent 
unavoidable. 

It  is  probable,  however,  that  in  the  case  of  mammals  whose 
digestive  tract  usually  contains  large  numbers  of  micro- 
organisms, certain  types  of  bacteria  which  are  normally  found  in 
great  numbers  in  the  intestinal  contents  are  actually  of  value  to 
the   animal  in   keeping  down   and  suppressing  the  growth  of 


38  BACTERIOLOGY    OF 

other  and  more  harmful  bacteria  which  may  from  time  to  time 
obtain  an  entrance.  The  best  instance  of  this  is  seen  in  the 
case  of  B.  coli.  Immense  numbers  of  B.  colt  are  normally 
present  in  the  human  intestine,  and  experiments  show  that  they 
tend  to  hinder  the  development  of  putrefactive  decomposition 
of  the  intestinal  contents,  and  also  to  combat  the  growth  of 
injurious  saprophytes  usually  present.  Thus  fluids  liable  to 
undergo  rapid  putrefaction  may  be  kept  for  days  or  even  weeks 
without  change  if  they  contain  large  quantities  of  B.  coli,  even 
though  B.  putrificans  be  added  ;  whereas,  if  B.  coli  be  not 
present,  putrefaction  will  occur  rapidly. 

The  Distribution  of  Bacteria  in  the  Intestinal  Tract. — 
The  greatest  number  of  bacteria  are  found  in  the  large  intestine. 
In  dogs  the  large  intestine  is  closely  crowded  with  bacteria  just 
beyond  the  ileocsecal  valve,  whatever  may  be  the  conditions  of 
the  ileum.  The  living  bacteria,  however,  steadily  decrease  in 
number  as  we  pass  down  the  colon,  so  that  in  the  rectum  the}' 
are  much  less  numerous  than  in  the  ascending  colon  and  csecum. 

There  is  some  reason  to  suppose  that  in  certain  cases  of  disease 
of  the  colon  what  may  be  called  the  "  phenomenon  of  substitution 
of  one  type  of  bacteria  for  another  "  occurs.  In  other  words, 
the  colon  bacillus,  which  is  the  normal  dominant  organism  of 
the  large  intestine,  becomes  replaced  by  another  form  of 
organism  which,  though  normally  present,  exists  only  in  small 
numbers  under  conditions  of  health.  Thus  Herter  quotes  the 
case  of  a  woman  suffering  from  colitis,  in  whom  the  dominant 
B.  coli  disappeared  and  was  replaced  b}^  a  different  organism, 
but  with  restoration  to  health  the  B.  coli  again  became  the 
dominant  organism. 

Lactic  Acid  Bacilli. — Recently  this  phenomenon  of  substitution 
has  been  taken  advantage  of  as  a  means  of  treating  certain 
infective  diseases  of  the  colon.  Prof.  Metchnikoff  was  the  lirst 
to  point  out  the  principles  of  treating  certain  diseases  of  the 
colon  by  the  administration  of  curdled  milk,  and  his  methods 
have  since  been  elaborated  by  several  other  workers,  notably 
by  Cohendy  working  at  the  Pasteur  Institute,  and  Herschell 
in  this  countrv.  *  The  principle  of  the  treatment  consists 
in  giving  by  the  mouth  large  quantities  of  the  Bulgarian 
lactic  acid  bacillus,  either  in  pure  culture  or  in  the  form  of  soured 


*  "  Soured  milk  and  pure  cultures  of  lactic  acid  bacilli  in  the  treatment 
of  disea.se  "  (G.  Herschell). 


THE    COLON  39 

milk.  This  bacillus  is  able  to  escape  the  action  ot  the  gastric 
juices,  and  on  reaching  the  colon  it  inhibits  the  growth  of  proteo- 
lytic microbes  which  it  finds  there,  and  even  destroys  them. 
The  effect  of  its  introduction  is  to  enormously  reduce  the  number 
of  other  bacteria  in  the  stools,  and  even  occasionally  to  entirely 
get  rid  of  them.  The  lactic  acid  bacteria,  in  fact,  are  substituted 
for  the  ordinary  microbes  present  in  the  colon,  and  as  they  are 
quite  harmless  to  the  host,  we  are  thus  enabled  to  replace  harmful 
organisms  in  the  colon  by  others  which  we  know  to  be  harmless. 

The  Bulgarian  bacillus  occurs  normally  in  the  human  faeces, 
but  only  in  small  quantities.  It  is  a  large  bacillus,  which  stains 
easily  b}'  the  usual  methods  and  is  Gram -positive.  It  may  be 
cultivated  in  milk,  in  milk  serum  to  which  i'5  of  peptone  has 
been  added,  and  upon  milk  peptone  agar.  On  the  latter  it 
grows  in  round  whitish  colonies.  It  can  be  administered  by  the 
mouth,  either  as  soured  milk,  or  as  liquid  or  dried  cultures. 
After  it  has  been  administered  for  a  short  time  it  replaces  the 
putrefactive  bacteria  in  the  colon,  and  may  be  found  in  the 
faeces  in  almost  pure  culture.  It  has  been  much  used  in  the 
treatment  of  autointoxication,  a  condition  in  which  there  is 
sometimes  excessive  bacterial  growth  in  the  colon.  It  inhibits 
the  growth  of  Bacillus  colt,  and  may  therefore  be  used  in  cases 
where  we  suspect  this  organism  of  causing  disease. 

Experiment  shoxmng  Conditions  of  Anaerobic  Growth  in  the 
Intestine  of  the  Dog  (Herter). — Dog  weighing  14I-  lbs.  The 
dog  was  given  200  mgrams  of  methylene  blue  in  water.  On 
the  third  day  he  was  given  100  mgrams  of  methylene  blue 
in  a  piece  of  cooked  meat.  Four  hours  after  eating  the  meat 
he  was  killed  and  the  intestine  examined.     The  stomach  was 

Ileocascal 
Stomach.  vaive.  Rectum. 


BCD 


Diagram  indicating  points  at  which  intestines  were  e.xamined. 

intensely  blue.  The  duodenum  w^as  blue,  but  the  intensity 
of  the  colour  diminished  towards  B  ;  at  C  the  colour  had  almost 
disappeared,  while  it  had  entirely  gone  between  C  and  D.  The 
contents  of  the  intestine  at  D  only  became  blue  on  exposure  to 
air.  The  contents  of  the  intestine  between  E  and  F  were  not 
blue  until  exposed  to  air. 


40        BACTERIOLOGY    OF    THE    COLON 

This  experiment  indicates  that  beyond  the  middle  of  the 
small  intestine  the  conditions  become  rapidly  anaerobic,  since 
the  reduction  of  methylene  blue  could  not  occur  in  the  presence 
of  air  in  this  concentration. 

Bacillus  cold. — The  question  as  to  whether  the  B.  coli  can 
become  virulent  and  cause  pathological  processes  within  the 
colon  is  a  difficult  one.  (I  am  leaving  out  of  account  for  the 
present  any  pathological  processes  which  may  result  from  B.  coli 
that  have  reached  other  tissues — as  by  perforation  of  the 
bowel  wall,  etc.) 

The  subject  is  the  more  difficult  as,  in  most  cases  in  which  it 
would  appear  that  a  pathological  process  has  been  set  up  in  the 
colon  by  B.  coli,  the  organism  has  not  been  properh'  identified, 
and  man}'  other  intestinal  organisms  closely  resemble  the  B.  coli, 
and  cannot  be  distinguished  from  them  except  by  careful  bio- 
chemical tests.  It  seems  probable  that  B.  coli  cannot  initiate 
putrefactive  processes  in  the  colon,  but  if  putrefacti\'e  anaerobes 
be  present,  the  B.  coli  can  take  an  acti\'e  part  in  breaking  down 
hydrolysed  proteids. 

Tubercle  Bacilli. — In  cases  of  intestinal  tuberculosis,  and 
especially  if  ulcerative  lesions  of  the  alimentar}'  tract  are  present, 
it  is  usual  for  tubercle  bacilli  to  be  found  in  the  stools,  and  these 
may  readily  be  demonstrated  b}-'  suitable  methods. 

Owing,  however,  to  the  large  number  of  organisms  usualh' 
present  in  fseces,  it  is  necessary  that  a  very  careful  examination 
be  made  to  prevent  the  possibility  of  confusing  other  and  similar 
organisms  for  the  tubercle  bacillus.  Quite  apart,  however, 
from  intestinal  tuberculosis,  it  is  not  uncommon  to  find  the 
tubercle  bacillus  in  faeces.  Rosenberger,  with  a  view  of  deter- 
mining how  frequently  tubercle  bacilli  are  present  in  fseces, 
examined  the  stools  of  672  patients  in  the  wards  of  the  Phila- 
delphia General  Hospital.  The  cases  examined  included 
pneumonia,  typhoid,  erysipelas,  diarrhoea,  and  numerous  other 
conditions,  both  medical  and  surgical,  and  some  apparenth' 
healthy  patients.  In  sixty  of  the  cases  some  form  of  tuberculous 
lesion  was  known  to  be  present.  In  all  these  60  cases  tubercle 
bacilli  were  present  in  the  fseces,  while  in  120  of  the  other  cases, 
or  in  1 9 "6  per  cent,  tubercle  bacilli  were  found  in  the  stools. 

From  this  it  is  obvious  that  too  much  significance  must  not  be 
attached  to  the  presence  of  acid-fast  bacilli  in  the  stools,  and  that 
they  may  be  present  without  any  intestinal  tuberculous  lesion. 


41 


Chapter    V. 

METHODS    OF    DIAGNOSIS. 

The  colon  is  a  very  inaccessible  portion  of  the  human  body,  and 
when  the  site  of  disease  is  unknown  it  is  not  easy  correctly  to 
diagnose  the  condition  or  to  ascertain  the  position  and  nature 
of  the  lesion.  There  are,  however,  at  the  present  day,  several 
means  at  our  disposal  by  which  we  can  obtain  exact  and 
reliable  data  to  aid  us  in  accurately  diagnosing  the  cause  of  the 
symptoms  and  the  situation  of  the  lesion.  It  is  often  necessary 
to  employ  several  or  all  of  these  in  the  same  case,  to  carefully 
compare  the  results,  and  examine  them  in  reference  to  the 
symptoms  and  history,  before  attempting  to  make  a  diagnosis. 

In  any  difficult  case  it  is  seldom  either  possible  or  advisable  to 
attempt  a  diagnosis  as  to  the  condition  present  in  the  colon  from 
a  single  examination,  and  several  days  are  often  necessary  to 
complete  a  thorough  investigation. 

Until  quite  recently,  disease  of  the  colon  was  generally  diag- 
nosed from  the  symptoms,  but  whenever  possible,  we  should 
base  our  conclusions  upon  facts  rather  than  symptoms,  as  the 
latter,  especially  in  the  case  of  the  colon,  are  extremely  un- 
reliable and  misleading. 

History  and  Symptoms. — The  patient's  past  history,  as 
well  as  the  history  of  the  symptoms,  should  be  most  carefully 
gone  into. 

If  there  is  pain,  it  is  necessary  to  ascertain  the  time  at  which 
it  comes  on,  its  duration,  severity,  whether  relieved  bv  lying 
down  or  stooping,  its  position,  and  so  on.  The  history  of  the 
present  symptoms  should  be  enquired  into,  and  any  history  of 
previous  abdominal  or  bowel  trouble  is  most  important,  such  as 
appendicitis,  peritonitis,  gastric  ulcer,  etc. 

The  condition  of  the  stools  should  be  enquired  into  :  whether 
there  is  blood  or  discharge  ;  if  there  is  mucus,  and  whether  in  the 
form  of  shreds,  slime,  or  casts.     Their  colour  and  consistence. 


42  METHODS    OF    DIAGNOSIS 

whether  soHd  or  hquid,  are  all  important  points.  If  there  is 
diarrhoea,  it  is  important  to  know  whether  much  or  little  is 
passed  at  a  time,  how  many  stools  there  are  in  twenty-four  hours, 
whether  there  is  tenesmus,  the  time  of  day  at  which  the  stools 
are  most  frequent,  and  especially  whether  there  is  a  desire  to  go 
to  stool  on  first  rising  in  the  morning. 

If  there  is  constipation,  we  must  ask  whether  aperients  are 
taken,  and  if  so,  in  what  quantities,  and  how  often  ;  also  whether 
there  are  periods  of  diarrhoea.  We  should  ask  whether  the 
patient  has  lost  weight  ;  if  so,  how  much,  and  in  what  time.  It 
must,  however,  be  remembered  that  diarrhoea,  if  it  has  persisted 
for  some  time,  almost  invariably  results  in  loss  of  weight. 

Many  patients  who  suffer  from  bowel  troubles  are  very 
neurotic,  and  inclined  to  attach  unnecessary  importance  to  their 
symptoms  and  to  exaggerate  them.  For  this  reason  it  is  advisable 
to  obtain  some  estimate  of  the  amount  of  pain,  discomfort,  and 
other  symptoms  which  depend  upon  the  patient's  sensations, 
by  asking  about  the  details  of  his  daily  life.  Thus,  if  the  patient 
complains  of  severe  abdominal  pain,  we  can  often  gauge  its 
severity  by  ascertaining  whether  he  has  to  go  to  bed,  whether 
it  interferes  with  his  occupation,  and  if  it  prevents  his  sleeping. 

It  is  important  to  go  carefully  into  the  history  of  the  case,  as 
by  so  doing  we  gain  the  patient's  confidence,  and  at  the  same  time 
form  a  valuable  estimate  of  the  gravity  of  the  condition,  and  get 
an  indication  as  to  the  probable  cause  of  the  trouble  ;  but  it  is 
the  greatest  mistake  to  attempt  a  diagnosis  from  the  history  and 
symptoms  alone.  Such  a  diagnosis  is  more  than  likely  to  be 
wrong  ;  the  history  and  symptoms  are  frequently  most  mis- 
leading, and  it  is  better  not  to  allow  ourselves  to  be  biassed 
towards  any  particular  diagnosis  until  a  thorough  examination 
has  been  made.  After  the  results  of  this  are  known,  the 
history  of  the  case  should  be  carefully  studied  with  the  object 
of  explaining  the  findings,  and  for  confirmatory  evidence.  In 
fact,  the  examination  should  form  the  ground-work  for  the 
diagnosis,  and  the  history  and  symptoms  should  be  considered 
secondary.  Too  often  the  diagnosis  is  built  up  the  other  way, 
and  facts  are  made  to  fit  the  evidence,  whereas  the  evidence 
should  only  be  used  to  confirm  and  supplement  the  facts. 

General  Inspection. — We  should  notice  whether  the  patient 
is  fat  or  thin,  and  if  the  latter,  whether  there  is  emaciation.  The 
presence   of   anaemia   or   cachexia   may   also   be   noticed.     The 


METHODS    OF     DIAGNOSIS  43 

condition  of  the  abdomen  is  important,  especially  as  to  whether 
it  is  flat  or  distended,  whether  the  abdominal  wall  is  firm, 
flabby  or  pendulous.  The  presence  or  absence  of  hernia  should 
always  be  noted.  The  patient  should  be  examined  standing  up 
with  the  abdomen  exposed,  to  ascertain  whether  there  is  anv 
bulging  of  the  lower  abdomen,  as  is  often  the  case  in  visceroptosis. 

Palpation  of  the  Abdomen. — For  this  purpose  the  patient 
must  be  placed  in  the  correct  position.  The  head  and  shoulders 
should  be  supported  on  a  pillow,  and  the  knees  should  be  well 
drawn  up.  so  that  the  feet  rest  flat  on  the  couch  and  do  not  tend 
to  slip  down.  The  patient  is  told  not  to  talk,  and  to  allow  the 
abdomen  to  be  as  loose  as  possible.  The  whole  abdomen  must 
be  carefully  palpated.  An\'  tender  spots  should  be  noted,  and 
whether  the  tenderness  is  deep  or  superficial. 

The  colon,  if  normal,  cannot  be  felt,  but  in  many  abnormal 
conditions  it  can  be  distinctly  felt,  especialh'  on  the  left  side. 
Of  course,  if  the  sigmoid  is  loaded  with  fffices,  it  can  easily  be 
felt,  and  it  is  always  advisable,  when  possible,  to  examine  the 
abdomen  again  after  the  bowels  have  been  well  cleared  with 
aperients  or  enemata.  Tumours  may  be  felt  after  the  bowels 
have  been  well  emptied,  which  w^ere  quite  impalpable  previously. 

Additional  information  may  sometimes  be  obtained  b}'  placing 
the  patient  in  different  positions,  as  for  instance  on  the  side, 
and  in  the  knee-elbow  position. 

Before  leaving  the  examination  of  the  abdomen,  the  stomach 
should  be  mapped  out  by  percussion,  as  its  lower  border  is  a 
useful  guide  to  the  position  of  the  transverse  colon.  Both  this 
and  the  lower  border  of  the  liver  should  be  marked  while  the 
patient  is  lying  down,  and  then  with  the  patient  standing  the}- 
should  be  marked  out  again,  when  if  visceroptosis  is  present 
there  will  be  a  considerable  difference  in  the  two  positions. 

As  an  aid  to  percussion,  the  bowel  may  in  some  cases  be 
gently  inflated  with  air  introduced  per  anum,  after  the  bowel 
has  been  emptied.  This  will  enable  us  to  ascertain — often  with 
considerable  accuracy — the  position  of  the  sigmoid  flexure  and 
transverse  colon. 

This  method  of  inflating  the  bowel  requires  to  be  employed 
with  considerable  caution,  and  on  no  account  should  air  be 
forcibly  introduced  into  the  bowel,  as  I  have  seen  recommended. 
The  bowel  ma}-  easily  be  ruptured  by  forcible  distention,  and 
considerable    pain    will    certainh-    be    caused.     The    method    I 


44 


SIGMOIDOSCOPY 


prefer  is  to  place  the  patient  in  the  knee-elbow  position  and 
pass  a  rectal  tube.  This  allows  air  to  pass  into  the  empty  colon 
under  normal  atmospheric  pressure,  and  if  then  the  tube  is 
removed,  and  the  patient  examined  in  the  recumbent  position, 
the  sigmoid  can  usually  be  readily  mapped  out. 

If  the  examination  is  to  be  completed  at  one  sitting,  it  is 
advisable  to  postpone  the  palpation  of  the  abdomen  until  after 
the  sigmoidoscope  has  been  used,  otherwise  the  examination  of 
the  abdomen  may  force  faecal  matter  down  into  the  sigmoid,  and 
thus  interfere  with  the  use  of  the  instrument. 

SIGMOIDOSCOPY. 

This  is  perhaps  the  most  valuable  means  we  have  of  examining 
the  colon,  and  should  never  be  omitted.     It  is  true  that  with  the 


Fig.   15. — Author's  modification  of  Strauss's  sigmoidoscope. 


sigmoidoscope  we  can  only  examine  the  pelvic  portion  of  the 
colon,  and  this  is  only  a  small  part  of  the  whole  ;  but  on  the 
other  hand,  this  is  the  part  most  commonly  diseased,  and  when 
other  parts  of  the  colon  are  diseased,  the  pelvic  portion  also  is 
generally  involved. 

There  are  several  different  patterns  of  sigmoidoscope,  but  by 
far  the  best  is  that  originally  designed  by  Professor  Strauss. 
The  author  has,  however,  slightly  modified  the  original  instru- 
ment [Fig.  15),  and  has  substituted  metal  filament  lamps,  which 
only  require  two  or  four  volts,  for  the  original  carbon  ones. 
The.se  lamps  give  a  better  light  and  do  not  get  hot,  while  they 
have  the  additional  advantage  of  working  off  a  small  batter}', 
which  is  easily  portable. 


SIGMOIDOSCOPY 


45 


The  chief  difficulty  in  making  a  satisfactory  examination  is 
to  get  the  sigmoid  flexure  empty.  It  is  only  when  very  skilfully 
administered  that  the  entire  sigmoid  can  be  emptied  by  enemata. 
The  best  plan  is  to  give  a  rhubarb  or  colocynth  pill  twenty-four 
hours  before  the  examination,  followed  by  a  plain  warm-water 


/■/;'.  ifi. — A  portable  accumulator  fitted  with  a  rheostat  for  working  the  sigmoidoscope. 


enema  some  three  or  four  hours  before  the  examination.  In 
cases  of  ulcerative  colitis  or  stricture,  it  is  better  to  omit  the 
aperient  and  use  only  the  enema. 

If  properly  manipulated,  the  instrument  does  not  cause  pain 
or  serious  discomfort,  and  an  anaesthetic  is  not  necessary,  though 
it  is  sometimes  advisable. 


46 


SIGMOIDOSCOPY 


The  patient  may  be  examined  either  in  the  knee-elbow  position, 
or  in  the  left  Sims'  or  semi-prone  position.  The  former  is  the 
easier  position  for  the  surgeon  {Fig.  17),  the  latter  the  most 
comfortable  for  the  patient.  If  the  semi-prone  position  be 
adopted,  a  small,  hard  cushion  should  be  placed  under  the 
left  hip,  the  knees  should  be  well  drawn  up,  and  the  feet  placed 
well  forward,  so  as  to  be  out  of  the  way  of  the  surgeon  {Fig.  18). 
The  examination  is  best  made  with  the  patient  on  a  high  couch 
or  operating-table. 

Method  of  Passing  the  Tube- — Before  introducing  the  tube, 
the  portion  carrying  the  lamp  is  withdrawn  and  the  obturator 


/'».  17. — Sigmoidoscopic  examination  of  the  colon  with  the  patient  in  the  genu-pectoral  position. 


inserted.  The  instrument  should  then  be  warmed  by  pouring 
some  hot  water  over  it.  This  is  better  than  dipping  into  hot 
water,  as  the  inside  of  the  tube  is  not  made  wet.  The  tube  should 
then  be  well  smeared  over  with  vaseline,  and  some  vaseline  put 
on  the  anus.  The  instrument  should  be  carefully  inserted  into 
the  anus,  and  pushed  gently  onwards  till  it  has  entered  about 
four  inches  ;  the  end  of  the  instrument  should  be  kept  in  a 
backward  direction  toward  the  sacrum.  As  soon  as  it  has  gone 
in  this  distance  the  obturator  should  be  removed,  and  the  lamp 
portion  of  the  tube  inserted  in  its  place.  The  switch  can  now 
be  turned  on,  and  a  little  air  pumped  into  the  bowel  by  means  of 


SIGMOIDOSCOPY 


47 


the  rubber  bellows.  The  tube  should  now  be  passed  gently 
(mwards  by  sight.  The  surgeon  should  look  for  the  lumen  of 
the  bowel,  and  gently  insinuate  the  end  of  the  tube  into  it,  if 
necessar}'  pumping  in  a  little  air  to  open  out  the  bowel  walls. 
All  manipulations  should  be  as  gentle  as  possible.  The  end  of 
the  instrument  must  not  be  pressed  against  the  mucous  mem- 
brane, but  the  folds  of  the  bowel  pushed  aside  by  a  slight  puff 
of  air.  In  this  way  the  instrument  is  passed  by  sight,  and  the 
end  of  the  tube  need  not  even  touch  the  mucous  membrane, 


/^/jf.  i3. — The  Sims'  position  for  passing  the  sigmoidoscope. 


but  work  its  way  behind  a  cushion  of  air.  Thus  there  is  no 
danger  of  causing  damage  to  the  walls  of  the  bowel,  however 
diseased  they  may  be.  It  is  necessary,  in  order  to  ensure  success, 
that  the  direction  of  the  bowel,  when  tracing  it  up  from  the  anus, 
should  be  remembered.  At  first  the  bowel  passes  backwards, 
following  the  curve  of  the  sacrum,  then  it  turns  very  sharply 
forward  to  pass  over  the  sacral  prominence,  and  in  order  to  get 
the  end  of  the  tube  over  this  prominence  it  must  be  carried 
forward. 

At  the  junction  of  the  rectum  with  the  sigmoid  there  is  always 


48  ,  SIGMOIDOSCOPY 

a  well-developed  fold  of  mucous  membrane  similar  to  the  valves  of 
Houston.  This  partly  occludes  the  bowel  lumen,  and,  being 
situated  anteriorly,  the  end  of  the  instrument  is  very  liable  to 
be  caught  by  it  as  it  is  being  carried  forward  over  the  sacral 
prominence.  It  is  partly  this  valve,  and  partly  the  sharp  bend 
of  the  bowel  which  usually  occurs  here,  that  makes  it  difficult 
to  pass  the  instrument  into  the  sigmoid  flexure.  As  a  rule,  the 
sigmoid  passes  to  the  left  just  after  the  recto-sigmoidal  junction, 
but  this  is  not  invariable,  and  it  may  be  found  to  pass  to  the  right 
or  straight  forward  in  exceptional  cases. 

As  has  been  stated,  considerable  difficulty  may  be  experienced 
in  getting  the  instrument  to  enter  the  sigmoid.  The  upper 
portion  of  the  rectum  below  the  recto-sigmoidal  junction  is 
very  capacious,  and  often  forms  a  sort  of  cul-de-sac  behind 
this  junction  ;  or,  at  any  rate,  there  appears  to  be  such  a 
cul-de-sac  in  certain  cases,  ^^^hat  happens  is  that,  after  the 
tube  has  passed  over  the  sacral  prominence,  the  bowel  appears 
to  end  blindly,  no  continuation  of  the  lumen  being  observable. 
In  such  cases  the  opening  into  the  sigmoid  wall  usually  be  found 
situated  lower  down  and  anteriorly. 

^^''hen  the  end  of  the  tube  has  entered  the  sigmoid  flexure,  it 
usually  has  to  be  deflected  rather  towards  the  patient's  left  side, 
though,  as  has  already  been  stated,  it  may  have  to  be  passed  to 
the  right  side  in  exceptional  cases.  The  tube  is  a  straight  one, 
and,  of  course,  cannot  go  round  curves  ;  but  what  really  happens 
is  that  the  sigmoid  flexure,  which  is  a  freely  movable  portion  of 
the  bowel,  is  threaded  on  to  the  instrument  much  in  the  same 
way  as  the  finger  of  a  glove  is  drawn  on  a  stick. 

Care  must  be  used  in  negotiating  sharp  curves,  and  on  no 
account  must  the  instrument  be  forced  round  the  curve  if  there 
is  definite  resistance.  The  use  of  force  under  such  circumstances 
causes  pain  by  putting  the  mesentery  on  the  stretch,  and  might 
even  tear  it.  With  practice,  there  is  usually  little  difficulty 
in  passing  the  instrument  to  its  full  length.  The  changes 
in  the  direction  of  the  tube  while  being  passed  are  shown 
roughl}"  in  the  diagram  [Fig.  ig). 

After  the  tube  has  been  introduced  as  far  as  it  will  go,  it  is 
slowly  withdrawn,  during  which  operation  the  whole  lumen  of 
the  bowel  comes  into  view,  and  any  growth,  ulceration,  or  other 
abnormality  present  can  be  detected  and  examined.  Should  a 
growth  be  found,  its  exact  dimensions  can  easily  be  ascertained. 


SIGMOIDOSCOPY 


49 


and  by  watching  whether  or  not  it  moves  with  the  intestinal 
wall  on  inflating  the  bowel,  or  by  pushing  it  gently  with  the  end 
of  the  tube,  one  can  easily  determine  its  mobility  and  estimate 


Fig.  ig.— Diagram  to  show  the  successive  deflections  of  the  instrument  which  are  necessary 
in  the  process  of  introduction.  The  arrows  show  the  direction  of  the  tube  at  each  point.  The 
bend  of  the  bowel  to  the  left  at  the  recto-sigmoidal  junction  is  indicated,  together  with  the 
approximate  positions  of  the  valves  of  Houston. 


Fig.  20.— Diagrammatic  drawing  showing  the  instrument  in  position  for  examining  a  growth  at 
the  lower  end  of  the  sigmoid  flexure. 

the  chances  of  successfully  removing  it  by  operation.  The 
distance  of  any  lesion  from  the  anus  is  ascertained  by  looking 
at  the  graduated  scale  on  the  outside  of  the  tube.     Should  it 

4 


50  SIGMOIDOSCOPY 

be  necessary  to  swab  away  an}'  blood  or  ftecal  material  from  the 
surface  of  the  growth,  or  even  to  remove  portions  of  it  for  micro- 
scopical examination,  this  can  be  done  by  removing  the  back 
glass  of  the  instrument  and  passing  swabs  on  special  holders 
down  the  tube,  or  by  using  special  forceps  made  for  the  purpose. 
The  distance  to  which  the  instrument  can  be  passed  varies 
considerably  with  different  patients.  In  those  who  have  a  long 
sigmoid  mesentery  and  no  adhesions  round  the  bowel,  it  is 
usually  possible  to  pass  the  instrument  to  its  full  length,  and  to 
see  well  beyond  the  middle  of  the  sigmoid  flexure.  When, 
however,  the  mesentery  is  short,  or  the  bowel  is  surrounded 
by  adhesions,  it  cannot  be  passed  beyond  the  last  loop  of  the 
sigmoid. 


Pis.   21. — Left  internal  iliac  artery  seen  through  the  wall  of  the 
sigmoid  flexure. 

The  instrument  is  not  so  easily  passed  in  women  as  in  men, 
chiefly  owing  to  the  fact  that  the  angle  of  the  sacrum  is  much 
greater  in  women,  and  consequently  the  rectum  has  a  greater 
curve. 

I  have  had  considerable  experience  with  this  instrument, 
and  have  never  met  with  any  unpleasant  results  from  its 
use.  Instances  have  occurred  in  which  the  bowel  has  been 
damaged,  but  this  has  only  happened  to  inexperienced  operators, 
and  has  been  due  to  the  use  of  force  when  introducing  the  tube. 
Under  no  circumstances  should  any  force  be  used,  and  once  it 
has  entered  the  rectum  it  should  be  passed  entirely  by  sight. 

One  little  warning  in  connection  with  the  use  of  the  sigmoido- 
scope   is    worth    giving.      If    during    the    examination    it    is 


THE    USE    OF   X  RAYS    IN    DIAGNOSIS    51 

necessary  to  remove  the  lamp  attachment,  or  to  open  the  back 
of  the  tube  by  removal  of  the  glass  window — as,  for  instance, 
when  a  swab-holder  or  other  instrument  is  to  be  passed  down 
the  tube — ^the  air  should  be  allowed  to  escape  slowly,  either  by 
the  tap  or  by  opening  the  glass  window  slowly.  If  this  is 
suddenly  removed,  and  there  is  any  pressure  of  air  in  the  bowel, 
the  bowel  wall  may  be  pushed  into  the  end  of  the  tube  when 
the  pressure  is  released,  and  the  mucous  membrane  be  injured. 

I  have  found  that  there  is  seldom  any  necessity  to  pump  in 
much  air  ;  all  that  is  required  is  an  occasional  puff  to  straighten 
the  bowel.  If  a  quantity  is  introduced  it  induces  peristalsis, 
which  defeats  the  surgeon's  object,  and  causes  the  patient 
discomfort. 

The  condition  of  the  mucous  membrane  of  the  pelvic  colon 
should  be  carefully  examined,  also  the  mobility  of  this  portion 
of  the  colon.  The  normal  sigmoid  flexure  is  quite  freely  movable 
in  all  directions,  and  if,  except  at  its  junction  with  the  rectum, 
it  is  found  to  be  fixed  and  cannot  be  moved  from  one  position, 
we  may  assume  the  presence  of  adhesions  or  a  tumour,  though 
there  is  the  possibility  of  a  very  short  mesocolon. 

Those  readers  who  wish  to  learn  to  use  the  instrument  are 
advised  to  read  The  Sigmoidoscope,  by  the  same  author. 

THE    USE   OF   X    RAYS 
IN   THE   DIAGNOSIS    OF    DISEASE    OF    THE    COLON. 

In  obscure  cases,  valuable  information  is  sometimes  obtained 
by  the  aid  of  X-ray  examinations.  The  method  is  somewhat 
dii!icult,  and  requires  the  very  best  apparatus  ;  small  installa- 
tions will  not  give  sufficient  penetration.  This  method  is 
particularly  useful  in  cases  of  ptosis  or  displacement  of  the 
colon,  and  has  also  been  employed  in  the  diagnosis  of  strictures. 
In  cases  of  constipation  it  may  be  used  to  ascertain  in  which 
portion  of  the  colon  the  delay  occurs.  Dr.  Hertz,  who  devised 
this  method  of  examining  cases  of  constipation,  has  by  means 
of  it  made  valuable  observations  in  such  cases. 

In  order  that  the  colon  may  throw  a  shadow,  it  is  necessary 
that  it  should  contain  some  substance  which  will  arrest  the  rays. 
For  this  purpose  bismuth,  suspended  in  a  liquid  or  semi-liquid 
vehicle,  is  usually  employed.  The  bismuth  may  either  be 
given  by  the  mouth  with  food,  or  injected  through  the  anus 
directly  into  the  colon.     The  method  adopted  depends  upon  the 


52    THE    USE    OF    X  RAYS    IN    DIAGNOSIS 

circumstances  of  the  case,  ^^'hen  we  wish  to  ascertain  either 
the  position  of  the  sigmoid  flexure,  or  if  there  is  a  stricture,  it  is 
better  to  inject  the  bismuth  directly  into  the  colon.  It  is  probabty 
also  the  better  method  in  cases  of  ptosis  of  the  transverse  colon. 
\\'hen,  however,  we  wish  to  examine  the  progress  of  a  test  meal 
through  the  colon,  the  bismuth  should  be  given  by  the  mouth. 

In  adopting  the  latter  plan  the  method  is  as  follows  : — 

The  patient  is  given  a  breakfast  consisting  of  bread  and  milk, 
with  which  two  ounces  of  bismuth  carbonate  have  been  well 
mixed.  The  bismuth  will  reach  the  caecum  in  a  normal  individual 
in  a  little  over  four  hours,  and  after  this  the  patient  must  be 
examined  periodically  with  the  X  raj^s.  The  patient  is  laid 
fiat  on  his  back  on  a  couch,  with  the  X-ra}^  tube  beneath  the 
couch  and  under  the  centre  of  the  abdomen.  A  coin  should  be 
placed  on  the  umbilicus,  as  it  affords  a  useful  landmark.  The 
screen  is  placed  across  the  abdomen,  and  on  this  is  laid  a  piece 
of  thin  tissue  paper.  The  outline  of  the  shadow  is  then  traced 
on  the  tissue  paper,  and  marks  made  to  indicate  the  positions  of 
the  umbilicus  and  anterior  superior  spines  ;  the  time  of  the 
examination  should  also  be  marked  on  the  paper.  A  series  of 
examinations  are  made,  and  afterwards,  b}'  comparing  the 
tracings,  the  point  at  which  delay,  if  any,  occurred  in  the  passage 
of  the  bismuth,  and  any  abnormalities  in  the  position  of  the 
different  portions  of  the  colon,  can  be  seen.  It  is  not  correct, 
however,  to  assume,  because  we  find  the  bismuth  unduly 
delayed  in  its  passage,  through  the  ascending  colon  for  instance^ 
that  therefore  the  cause  of  its  delay  is  at  the  hepatic  flexure. 
It  ma}"  equalh'  well  be  in  the  sigmoid  flexure,  the  bismuth 
being  arrested  because  the  bowel  contents  in  front  of  it  cannot 
pass  on.  The  negative  evidence  is  valuable,  however,  as,  for 
instance,  if  we  find  that  the  bismuth  has  passed  in  about  the 
normal  time  through  the  colon  until  it  reaches  the  sigmoid 
flexure,  we  are  safe  in  assuming  that  there  is  no  obstruction  in 
the  rest  of  the  colon  (see  Fig.  12). 

The  normal  times  for  the  bismuth  to  reach  different  parts 
of  the  colon  are  given  by  Hertz  as  follows  :  To  reach  the  caecum 
4^  hours,  hepatic  flexure  6|  hours,  splenic  flexure  9  hours, 
sigmoid  flexure  about  12  hours. 

These  figures  are  only  approximate  ;  considerable  variations 
may  occur,  and  during  sleep  the  progress  is  much  slower. 

Where  the  bismuth  is  to  be  introduced  directlv  into  the  colon,. 


PLA  TE    II 


Radiograph  of  the  Pf.lvic  Colon  after  the  injection  of  bismuth  emulsion,  showing  a 
cancerous  stricture  at  the  recto-sigmoidal  junction. 

(Okinczvc,  Cancer  die  Colon  :  Steinheil,   Paris.) 


OF    DISEASES    OF    THE     COLON  53 

it  should  be  made  into  a  thick  emulsion  with  ohve  oil ;    the 
quantity  required  is  from  200  to  400  cc. 

The  patient  is  placed  in  the  genu-pectoral  position  during  the 
introduction  of  the  emulsion,  and  a  long  rectal  tube  is  passed 
into  the  sigmoid  flexure  by  means  of  the  sigmoidoscope,  the 
instrument  being  afterwards  withdrawn  over  the  tube  so  as  to 
leave  the  latter  in  place.  Unless  the  tube  is  passed  through  the 
sigmoidoscope  it  is  impossible  to  be  certain  that  it  is  in  the 


Fig.   22. — X  ray    photograph    of  a  patient  after  bismuth  emulsion  has  been  injected  into  the 
colon.     The  photograph  shows  extensive  prolapse  of  the  tranverse  colon — visceroptosis. 

{After  Schule,  from  La  Presse  Medicale.) 


sigmoid.  By  injecting  the  emulsion  through  the  tube  we  avoid 
distending  the  rectal  ampulla  and  so  causing  tenesmus,  the 
presence  of  the  emulsion  is  more  easily  tolerated,  and  a  larger 
quantity  can  be  introduced.  By  placing  the  patient  in  the 
genu-pectoral  position  the  emulsion  is  enabled  to  pass  up  into 
the  higher  parts  of  the  colon. 


54     THE   USE   OF  X  RAYS  IN    DIAGNOSIS 

If  the  patient  is  unable  to  remain  long  enough  in  this  position, 
the  injection  should  be  given  in  the  left  Sims'  position,  and 
the  foot  of  the  couch  well  raised  on  blocks.  The  X-ray  examina- 
tion is  made  in  the  same  way.  The  bismuth  seems  to  be  well 
tolerated  by  the  bowel,  and  does  not  cause  any  unpleasant 
consequences  as  a  rule.  A  stricture  in  the  bowel  is  generally 
indicated  by  a  dense  shadow  above  and  below  it,  but  deceptive 


Fi^.  23. — X-ray  photograph  of  a  patient  after  the  introduction  of  a  long  rectal  tube.     Note  that 
the  tube  has  curled  up  in  the  rectum  and  not  entered  the  colon. 

{After  Schule,  from  La  Presse  Medicate.) 


appearances  are  liable  to  occur.  These  methods  of  X-ray  diag- 
nosis in  disease  or  abnormalities  of  the  colon  are  comparatively 
new,  and  are  only  of  use  in  certain  cases.  The  results  so 
obtained  must  not  be  too  implicitly  relied  on,  but  used'  rather 
as  confirmatory  evidence.  "rii 

The  X  rays  are  of  the  greatest  value  in  localizing  foreign 
bodies  in  the  colon,  and  may  also  assist  in  the  detection  of 
stercoliths. 


OF    DISEASES    OF    THE    COLON  55 

Diagnosis    by  Means    of   Rectal    Bougies    and    Tubes- — 

The  use  of  rectal  bougies  for  the  diagnosis  of  strictures  in  the 
bowel  was  at  one  time  very  popular,  but  they  have  now  been 
entirely  replaced  by  the  sigmoidoscope  and  similar  instruments. 
It  is  well  that  it  is  so,  for  the  use  of  bougies  is  by  no  means  free 
from  danger,  and  there  have  been  numerous  accidents  due  to 
perforation  of  the  bowel  wall  ;  moreover,  they  are  of  very  little 
value  in  diagnosis,  as  the  end  may  easily  be  arrested  by  one  of 
the  rectal  valves,  and  so  give  the  impression  that  a  stricture 
exists,  when  as  a  matter  of  fact  there  is  none. 

Diagnoses  based  on  the  passage  of  a  rectal  tube  are  quite 
valueless.  One  not  uncommonly  hears  it  stated  that  a  patient 
in  whose  colon  the  presence  of  a  stricture  is  suspected,  has  no 
stricture  in  the  sigmoid  flexure,  because  a  rectal  tube  has  easily 
been  passed  for  two  feet.  This,  however,  proves  nothing,  as 
the  tube  usually  curls  up  in  the  rectum,  and  although  two  feet 
of  it  have  been  introduced,  the  end  may  lie  just  within  the  anus. 
Any  one  who  doubts  this  statement  has  only  to  examine  the 
patient  with  X  rays,  after  passing  the  tube,  to  be  convinced  ; 
they  will  see  the  tube  coiled  up  in  the  rectal  ampulla  {Fig.  23). 

The  only  way  in  which  a  long  tube  can  with  certainty 
be  introduced  into  the  colon  is  by  passing  it  through  the 
sigmoidoscope. 

It  is  very  doubtful  whether  a  tube  can  be  passed  up  the 
bowel  for  more  than  six  inches  once  in  twenty  times,  and  the 
so-called  high  enemas  given  with  a  long  tube  could  be  just  as 
well  administered  with  an  enema  nozzle. 

Examination  Under  an  Anaesthetic- — This  is  a  most 
valuable  aid  to  diagnosis  in  difficult  cases.  With  the  abdominal 
muscles  well  relaxed,  the  whole  colon  can  be  palpated,  and  if  a 
tumour  is  present  it  can  usually  be  felt.  A  bimanual  examina- 
tion should  also  be  made  with  two  fingers  in  the  rectum.  If 
the  sphincters  are  slightly  stretched,  the  two  first  fingers  of  the 
right  hand  can  easily  be  passed  into  the  bowel,  and  this  allows 
one  to  reach  nearly  an  inch  higher  than  if  only  one  finger  is 
employed.  By  bimanual  examination,  growths  in  the  lower 
third  of  the  sigmoid  can  usually  be  felt  through  the  anterior 
rectal  wall.  Abscesses  in  the  iliac  fossse  can  also  be  felt,  and 
the  pelvic  organs  explored. 

The  examination  should  first  be  made  with  the  patient  lying 
on  his  back,  and  he  should  then  be  turned  over  on  his  side,  and 


56     THE  USE   OF  X  RAYS  IN   DIAGNOSIS 

the  knees  well  drawn  up.  The  examination  should  then  be 
repeated.  The  change  in  attitude  maj^  allow  a  tumour  to  lall 
forward  into  a  position  in  which  it  can  be  more  easily  felt ;  also, 
when  a  tumour  has  already  been  detected,  valuable  information 
as  to  its  mobility  or  otherwise  is  afforded  by  palpation  with  the 
patient  in  different  positions. 

Exploratory  Laparotomy. — This  should  not  often  be 
necessary,  and  if  the  patient  has  been  carefully  examined  by 
the  means  already  mentioned,  an  approximate  diagnosis  will, 
at  any  rate,  have  been  arrived  at  in  most  cases.  Exploratory 
laparotomy  should  never  be  performed  unless  there  are  reason- 
able grounds  for  supposing  that  a  lesion  exists  which  can  only 
be  treated  satisfactorily  by  operation,  and  it  should  not  be 
used  merely  as  a  method  of  diagnosis.  Before  deciding  upon 
such  an  operation,  a  consultation  is  advisable,  and  the  question 
of  whether  the  results  likely  to  accrue  from  the  operation  are 
commensurate  with  the  risks,  will  have  to  be  carefully  considered. 

There  are  cases,  however,  where  there  is  good  reason  to  assume 
that  some  lesion  in  the  colon  exists  which  may  be  easily  remedied 
by  an  operation,  but  the  exact  situation,  or  even  its  actual 
presence,  cannot  be  determined  with  any  certainty  ;  in  such 
cases,  after  due  consideration,  exploratory  laparotomy  is  un- 
questionabh'  indicated. 

Examination  of  the  Stools.-^This  is  always  an  important 
factor  in  diagnosis,  which  should  never  be  omitted.  The  shape 
and  character  of  the  deposits  should  be  noted.  Liquid  stools, 
except  when  aperients  are  taken,  are  always  a  sign  of  something 
abnormal.  Constant  fluid  faeces,  mixed  with  jelly-like  mucus, 
generally  result  from  a  stricture  or  ulceration  in  the  bowel. 

Much  importance  is  often  attached  to  the  shape  of  the  faeces 
when  solid.  Thus  it  is  stated  that  ribbon-like  or  "  pipe-stem  " 
faeces  indicate  a  stricture  or  narrowing  in  the  bowel.  This  is  a 
most  fallacious  argument.  Though  it  is  true  that  if  a  stricture 
exists  at  the  anal  opening  the  faeces  may  be  flattened  or  other- 
wise altered  in  shape,  a  stricture  higher  up  in  the  bowel  cannot 
affect  the  shape  of  the  faeces,  as  the  mass  would  inevitably  be 
reformed  in  the  rectal  ampulla  and  must  take  its  shape  from 
the  last  narrow  opening  through  which  it  passes — the  anus. 

The  shape  and  form  of  the  faeces  are  of  little,  if  any,  diag- 
nostic value. 

The  presence  of  abnormal  constituents  is  important.     Mucus 


OF    DISEASES    OF    THE    COLON  57 

is  normally  present  in  the  stools,  but  not  in  sufficient  quantity 
to  be  obvious.  The  presence  of  large  quantities  of  mucus  is 
indicative  of  some  irritative  lesion.  Much  importance  is  often 
attached  to  the  form  in  which  the  mucus  is  found,  whether  it 
be  in  that  of  slime,  shreds,  or  casts.  It  is  doubtful,  however, 
whether  we  can  attach  any  significance  to  its  form.  A  patient 
will  at  one  time  pass  jelly-like  mucus  and  at  another  well- 
formed  casts  or  membranes.  I  have  seen  large  casts  passed 
by  patients  who  were  suffering  from  cancer  of  the  sigmoid. 
The  exact  reason  for  the  mucus  forming  casts  in  some  cases  and 
not  in  others  is  not  understood,  and  we  are  not  justified  in 
drawing  any  conclusions  from  their  presence  {vide  Chapter  IL). 

Blood. — The  presence  of  blood  in  the  stools  is  of  great 
importance,  as  it  indicates  the  presence  of  ulceration  or  some 
breach  of  surface — with  the  rare  exception  of  some  of  the 
haemophylic  conditions.  Blood  may  often  be  present  in  such 
small  quantity  that  it  is  not  obvious  to  the  naked  eye,  and  some 
test  for  its  presence  is  necessary.  There  are  several  chemical 
tests  for  blood  in  the  stools,  but  a  microscopical  examination  of 
the  faeces  affords  the  best  and  most  reliable. 

About  an  ounce  of  liquid  stool  should  be  collected  in  a  clean 
bottle,  and  to  this  about  the  same  quantity  of  5  per  cent  formalin 
solution  added.  A  microscopical  examination  demonstrates 
the  presence  of  blood,  undigested  food,  or  parasites,  and  may 
enable  us  to  detect  portions  of  malignant  growth. 

Urine. — A  careful  examination  of  the  urine  is  often  valuable, 
as  by  this  means  we  may  ascertain  whether  autointoxication 
is  occurring.  The  presence  of  indican  in  the  urine,  or  indican- 
uria,  shows  that  excessive  albuminous  putrefaction  is  occurring 
somewhere  in  the  body.  Its  presence  is  very  often  a  sign  of 
intestinal  putrefaction,  and  its  quantity  varies  with  the  activity 
of  that  process.  It  is  invariably  present  in  cases  of  severe 
constipation  in  which  there  is  autointoxication. 

Obermeyer's  test  for  indican  in  the  urine  is  as  follows  :  Take 
50  cc.  of  urine,  add  to  it  10  cc.  of  a  20  per  cent  solution  of  lead 
acetate  ;  then  filter.  The  filtrate  must  be  well  shaken  with  an 
equal  quantity  of  hydrochloric  acid  containing  between  o'2  and 
o'4  per  cent  ferric  chloride,  and  a  few  cubic  centimetres  of 
chloroform.  If  indican  is  present  in  the  urine,  indigo-blue  will 
be  formed,  and  will  pass  into  solution  in  the  chloroform. 


58 


Chapter  VI. 

CONGENITAL    ABNORMALITIES     OF     THE 
COLON. 

Congenital  abnormalities  of  the  colon  may  be  conveniently 
divided  into :  Congenital  abnormalities  of  the  colon  itself : 
and  Congenital  abnormalities  of  the  peritoneum  or  mesentery. 

CONGENITAL    ABNORMALITIES 
OF    THE    COLON    ITSELF. 

These  are  very  rare,  and  as  a  rule,  when  present,  are  found 
to  be  associated  with  congenital  abnormalities  in  other  parts. 

The  colon,  or  some  part  of  it,  may  be  completely  absent,  or 
represented  only  by  a  fibrous  cord.  Some  form  of  atresia  is 
the  commonest  condition  met  with.  Thus,  some  portion  of 
the  colon  may  be  represented  only  by  a  narrow  tube.  In 
Atkins'  case  the  whole  colon  and  rectum  were  rudimentary, 
and  about  the  thickness  of  an  ordinary  quill,  there  being  a  small 
lumen,  however,  throughout  the  colon.  The  condition  in  this 
case  was  associated  with  imperforate  anus. 

In  another  case,  the  ascending  and  transverse  portions  of  the 
colon  were  represented  by  a  narrow  tube  about  the  thickness 
of  a  lead  pencil,  while  the  remainder  was  normal,  except  for 
some  annular  contractions  in  the  sigmoid.  The  condition  in 
this  case  was  associated  with  an  hour-glass  contraction  of  the 
stomach,  and  a  stricture  of  the  ileum  just  above  the  ileocsecal 
valve,  also  of  congenital  origin. 

A  very  interesting  case  was  recorded  by  Anderson,  of  an 
infant  who  was  born  with  a  faecal  fistula  at  the  umbilicus  and 
an  imperforate  anus.  Post  mortem  it  was  found  that  the  faecal 
fistula  was  formed  by  the  ileum  immediately  above  the  ileo- 
caecal  valve  being  adherent  to  the  umbilicus.  The  caecum, 
ascending,  transverse,  and  descending  portions  of  the  colon  were 
present,  but  the  descending  colon  ended  in  a  blind  extremity. 
There  was  no  trace  of  any  sigmoid  flexure  or  rectum. 


CONGENITAL    ABNORMALITIES  59 

A  case  is  recorded  by  Lockwood,  in  which  the  descending 
colon  was  double.  The  two  tubes  were  parallel  with  each  other, 
and  both  were  provided  with  a  lumen  and  appendices  epiploicse  ; 
one  was,  however,  very  small,  while  the  other  was  of  fair  diameter 
and  performed  the  functions  of  the  descending  colon.  The 
patient  was  a  man,  aged  57,  who  died  at  St.  Bartholomew's 
Hospital  from  intestinal  obstruction.  There  was  a  malignant 
growth  at  the  lower  end  of  the  descending  colon  at  the  spot  at 
which  the  two  tubes  appeared  to  join  again. 

Congenital  stenosis  of  the  colon  is  very  rare,  but  there  are 
several  cases  on  record.  The  stenosis  may  consist  of  a  diaphragm 
or  may  take  a  tubular  form.  In  a  few  instances  more  than 
one  stricture  has  been  present. 

CONGENITAL     ABNORMALITIES 
OF     THE     PERITONEUM     OR     MESENTERY. 

The  commonest  congenital  abnormalities  of  the  colon  are 
those  in  which  there  has  been  some  failure  in  the  descent  of  the 
caecum,  or  rather  where  the  normal  development  of  the  peritoneal 
connections  of  the  colon  has  been  arrested.  It  is  obvious,  from 
a  study  of  the  development  of  the  colon  in  relation  to  its 
peritoneal  attachments,  that  any  abnormality  may  exist, 
between  the  colon  being  represented  by  a  practically  straight 
tube  and  the  normal  condition. 

If  arrest  of  development  takes  place  at  a  very  early  date,  the 
caecum  will  be  outside  the  abdomen,  and  the  colon  be  represented 
by  a  practically  straight  tube  between  the  umbilicus  and  the 
rectum. 

The  caecum  may  be  situated  in  the  left  side  of  the  abdomen 
(quite  apart  from  complete  transposition  of  the  viscera).  This 
may  occur  in  two  ways  :  (i)  From  arrested  development  at  an 
early  stage  before  the  caecum  has  passed  across  to  the  right 
hypochondrium,  or  (2)  From  persistence  of  the  caecal  mesentery 
allowing  the  caecum  to  migrate  to  the  left  side. 

In  Professor  Simpson's  case  the  caecum  was  retained  in  an 
umbilical  hernia  by  adhesions,  the  result  of  intra-uterine 
inflammation,  and  the  colon  retained  the  primitive  form  of  a 
straight  tube.  There  is  a  specimen  of  a  similar  case  in  the 
museum  of  the  Royal  College  of  Surgeons. 

The  caecum  may  be  found  on  the  left  side  of  the  abdomen 
near  the  spleen,  and  the  transverse  colon  be  absent.     Several 


6o  CONGENITAL    ABNORMALITIES 

such  cases  have  been  recorded,  and  in  most  of  them  it  is  stated 
that  the  caecum  was  fixed  by  adhesions.  It  seems  probable 
that  the  original  lesion  was  an  abnormal  mesentery  to  the 
caecum,  which  allowed  it  to  migrate  to  the  left  side  of  the 
abdomen,  where  it  became  fixed  by  adhesions. 

A  more  common  condition  is  for  the  caecum  to  fail  to  descend 
into  the  right  iliac  fossa,  and  to  remain  just  beneath  the  liver. 
This  condition  is  normally  present  in  many  mammals.  In  such 
cases  the  ascending  colon  is  unrepresented,  and  the  caecum 
communicates  directly  with  the  transverse  colon.  In  the  male 
the  non-descent  of  the  caecum  is  often  associated  with  imperfect 
descent  of  the  right  testicle. 

A  very  curious  case  was  reported  by  Elliott  Smith,  in  which 
the  caecum,  as  such,  appeared  to  be  absent.  The  ileum  passed 
insensibly  into  the  ascending  colon  without  any  trace  of  an 
ileocaecal  valve,  and  the  colon  had  a  gradual  curve  throughout, 
there  being  no  hepatic  or  splenic  angle.  The  whole  colon  was 
provided  with  a  mesentery.  The  appendix  was  present  in  the 
shape  of  a  solid  cord.    . 

The  Sigmoid  Flexure  opening  into  the  Rectum  on  the 
Right  Side. — This  is  a  not  uncommon  congenital  abnormality 
of  the  colon,  and  is  probably  present  in  about  4  per  cent  of  all 
cases.  Out  of  tWenty-one  newly-born  infants  dissected  by 
Curling,  the  sigmoid  joined  the  rectum  on  the  right  side  in  two. 
It  is  a  condition  well  recognized  by  surgeons,  as  it  is  a  cause  of 
considerable  embarrassment  when  attempting  to  perform  a  left 
inguinal  colotomy  in  such  cases. 

Caecum  and  Ascending  Colon  having  a  Mesentery- — 
Perhaps  the  commonest  form  of  congenital  abnormality  of  the 
colon  is  that  in  which  the  primitive  arrangement  of  the  periton- 
eum attaching  the  caecum  and  ascending  colon  to  the  posterior 
abdominal  wall  has  persisted.  The  condition  varies  from  the 
caecum  alone  having  a  short  and  complete  mesentery,  to  that  in 
which  the  caecum  and  ascending  colon,  and  half  the  transverse 
colon,  have  a  common  mesentery  with  the  whole  of  the  small 
intestine.  Any  condition  between  these  two  extremes  may 
be  met  with,  and  that  in  which  the  caecum  has  a  short  mesentery 
is  comparatively  common. 

The  caecum  in  such  cases  may  have  a  mesocolon  five  inches 
or  more  in  length,  and  may  be  free  to  move  about  the  abdominal 
cavity.     In  the  cases  in  which  it  possesses,  together  with  the 


CONGENITAL    DILATATION  6i 

ascending  colon  and  right  half  of  the  transverse  colon,  a  common 
mesentery  with  the  small  bowel,  the  cgecal  angle  of  the  colon 
(as  it  may  be  called)  occupies  a  more  or  less  central  position 
in  the  abdomen. 

This  condition  is  very  liable  to  result  in  the  formation  of  a 
volvulus,  often  of  a  most  complicated  character.  It  will  be 
further  considered  in  the  chapter  on  volvulus. 

Treatment  of  Congenital  Abnormalities. 

Many  of  the  congenital  abnormalities  of  the  colon  which  have 
been  mentioned,  such  as  complete  atresia  and  absence  of  some 
portion  of  the  large  bowel,  are  quite  incompatible  with  life,  and 
are  beyond  the  scope  of  surgical  interference. 

Most  of  the  abnormalities  are  of  practical  interest  chiefly 
because  they  give  rise  to  difficulties  in  operating  upon  the  colon, 
or  because  they  are  liable  to  result  in  volvulus.  Apart  from  the 
complications  which  thej'  may  cause,  they  are  seldom,  if  ever, 
diagnosed  during  life,  and  there  is  therefore  no  indication  for 
attempting  to  correct  them  by  surgical  means. 

The  displacements  of  the  caecum  and  sigmoid  are,  however, 
of  considerable  practical  importance  to  the  surgeon,  as  should 
the  necessity  arise  in  such  a  case  for  the  performance  of  a 
colotomy,  their  presence  may  render  the  operation  most  difficult, 
and  sometimes  impossible. 

This  was  more  especially  the  case  in  the  days  when  lumbar 
colotomy  was  the  usual  operation,  though  considerable  difficulty 
may  result  when  performing  an  inguinal  colotomy  if  the  colon 
is  not  found  in  its  usual  position. 

CONGENITAL     DILATATION     AND     HYPERTROPHY 
OF     THE     COLON. 

Probably  the  earliest  recorded  case,  and  certainly  the  first  in 
which  an  operation  was  performed,  is  that  reported  by  Dr. 
Bright  in  1838.  The  real  cause  of  the  condition  was  detected  by 
this  astute  observer,  but  he  labelled  the  case  "phantom 
tumour." 

The  condition  is  a  very  rare  one,  but  probably  not  so 
uncommon  as  hospital  records  seem  to  prove.  It  is  most  fre- 
quently met  with  in  children,  but  may  be  encountered  at  any 
age,  as  it  is  not  necessarily  fatal. 

A  great  deal  of  uncertainty^  still  exists  as  to  the  nature  and 


62  CONGENITAL    DILATATION    AND 

causes  of  this  disease,  and  it  has  been  described  under  several 
names,  such  as  "Hirschsprung's  Disease,"  "Idiopathic  Dilata- 
tion of  the  Colon,"  and  "  Congenital  Dilatation  of  the  Colon." 
The  name  used  here,  however,  is  that  which  best  describes 
the  condition. 

Symptoms. 

The  chief  symptoms  are  enormous  distention  of  the  abdomen, 
and  severe  and  intractable  constipation.  In  most  of  the  cases 
one  or  both  of  these  symptoms  are  noticed  within  a  few  days 
or  weeks  of  birth. 

In  several  instances  no  meconium  has  been  passed  for  three 
or  four  days  after  birth,  and  there  has  subsequently  been 
increasing  difficulty  in  relieving  the  bowels. 

Usually  constipation  is  the  first  symptom,  and  distention  of 
the  abdomen  is  only  manifest  later  ;  but  in  at  least  one  instance 
the  child  was  born  with  a  distended  abdomen,  while  in  a  case 
recorded  by  Walker  and  Griffiths,  the  distention  was  first 
noticed  when  the  child  was  a  few  weeks  old,  and  the  consti- 
pation not  till  the  age  of  three  years. 

The  distention  is  the  most  marked  characteristic.  One  child 
six  months  old  measured  23 J  inches  in  girth  at  the  umbilicus; 
a  boy  aged  eleven  years  had  a  girth  of  3  feet  11  inches. 

Formard  has  described  a  case  in  which  the  patient,  a  man, 
earned  his  living  as  a  freak  at  shows.  He  was  called  the  "  balloon 
man  "  on  account  of  the  enormous  size  of  his  abdomen.  In 
several  cases,  girls  suffering  from  the  disease  have  been  suspected 
of  pregnancy,  owing  to  the  size  of  their  abdomens.  The 
distention  is  mainly  due  to  flatus,  and  the  abdomen  is  always 
hyper-resonant.  In  extreme  cases  the  splenic  dullness  is 
obliterated,  and  the  liver  dullness  much  diminished. 

The  distention  is  usually  considerably  diminished  by  an 
action  of  the  bowels,  but  it  is  seldom  completely  relieved,  and 
usually  soon  reappears. 

When  there  is  great  distention,  secondary  symptoms  occur 
from  pressure  upon  other  organs  and  upon  the  diaphragm. 
There  may  be  marked  shortness  of  breath  and  dyspnoea,  the 
patient,  during  the  height  of  the  distention,  being  Uvid  in  the 
face  from  the  embarrassed  respiration.  Palpitation  may  occur, 
from  displacement  of  the  heart,  and  the  circulatory  system  may 
be   seriously   interfered    with.     The  pressure    results    in    great 


HYPERTROPHY    OF    THE    COLON        63 

enlargement  of  the  superficial  veins  of  the  abdomen,  and  in 
some  cases  has  caused  oedema  of  the  legs.  The  kidneys  may 
be  damaged,  and  albuminuria  is  sometimes  present. 

The  constipation  is  very  intractable,  the  bowels  often  remaining 
unrelieved  for  days  and  weeks,  in  spite  of  the  energetic  employ- 
ment of  aperients  and  enemata. 


Fig.  24. — A  boy,  aged  eleven,  with  congenital  dilatation  and  hj'pertrophy  of  the  colon. 

{After  Osier.) 


In  those  cases  which  survive  the  first  few  years  of  life,  there 
is  a  tendency  for  the  symptoms  to  occur  in  periodic  attacks, 
the  patient  often  going  months  and  even  years  without  suffering 
any  serious  inconvenience  from  the  condition  ;  but  constipa- 
tion and  unusual  distention  of  the  abdomen  persist  throughout. 
When  an  attack  comes  on,  the  patient  becomes  progressively 


64         CONGENITAL    DILATATION    AND 

more  distended,  and  the  bowels  refuse  to  act.  In  some  cases 
the  patient  goes  weeks,  and  even  months,  without  any  action 
of  the  bowels.  Sometimes  the  attack  terminates  in  a  copious 
action  of  the  bowels  which  relieves  the  symptoms,  to  be  followed 
in  a  few  weeks  or  months  by  another  similar  attack. 

The  constipation  may  be  so  severe  as  to  cause  typical  symptoms 
of  intestinal  obstruction  ;  the  patient  vomits,  and  suffers  severe 
pain  in  the  abdomen.  Great  coils  of  distended  colon  can  be 
seen  moving  about  through  the  stretched  abdominal  wall.  In 
many  cases  an  operation  has  been  necessary  to  relieve  the 
obstruction,  and  several  patients  have  died  from  obstruction. 

In  a  few  cases  the  bowels  have  only  been  relieved  by  the 
administration  of  chloroform.  One  of  the  author's  patients, 
a  man  of  23,  was  on  three  occasions  relieved  in  this  way,  an 
immense  mass  of  faecal  material  coming  away  under  the 
anaesthetic. 

The  constipation  is  usually  characterized  by  long  intervals 
during  which  there  is  no  action  of  the  bowels,  followed  by 
copious  stools.  Sometimes,  however,  there  is  spurious  diarrhoea, 
small  stools  occurring  at  frequent  intervals  without  any  actual 
relief. 

The  health  of  the  patient  generally  suffers  considerably, 
and  there  is  often  serious  emaciation  and  anaemia.  The  skin 
is  discoloured,  and  there  is  marked  toxaemia,  often  accompanied 
by  a  slight  rise  of  temperature.  In  a  few  cases,  however,  except 
during  the  attacks  of  obstruction,  the  patient  suffers  no 
inconvenience,  and  even  when  the  bowels  have  not  acted  for 
a  long  time  there  are  no  toxaemic  symptoms. 

Diagnosis. 

This  rests  mainly  upon  the  history  of  severe  constipation 
accompanied  by  distention  of  the  abdomen  from  birth  or 
childhood,  and  the  presence  of  an  enormously  dilated  colon. 
Examination  of  the  abdomen  reveals  great  distention  and 
tympanites.  The  lower  angle  of  the  ribs  is  flattened,  and  the 
chest  pushed  out  at  the  sides,  in  extreme  cases. 

The  abdominal  veins  are  often  enlarged.  If  the  abdomen 
is  examined  while  peristalsis  is  occurring  in  the  colon,  the  huge 
coils  of  dilated  bowel  can  often  be  seen  moving,  and  may  also 
be  felt.  In  one  case  of  the  author's,  the  contractions  of  the 
dilated  colon  felt  like  those  of  the  uterus  in  labour. 


HYPERTROPHY    OF    THE    COLON         65 

Examination  under  the  X  rays,  after  a  large  enema  containing 
bismuth,  will  often  enable  the  dilated  bowel  to  be  seen.  Most 
reliance,  however,  is  to  be  placed  on  an  examination  with  the 
sigmoidoscope,  as  the  interior  can  then  be  observed.  The 
interior  of  the  colon  under  such  circumstances  looks  hke  an 
immense  sac  almost  filhng  the  abdomen. 


Fig.  25. — Skiagram  in  Dr.  Carpenter's  case  of  congenital  dilatation  of  the  colon  after  a  large 
enema  of  Bismuth  emulsion.  It  will  be  noticed  that  the  ordinary  shape  of  the  colon  has 
disappeared,  and  that  there  is  one  large  U-shaped  sac. 


Etiology. 

The  condition  is  undoubtedly  congenital  .  in  origin.  This 
is  clearly  shown  by  the  age  tables,  and  by  the  fact  that, 
even  when  the  condition  is  present  in  an  adult,  there  is 
almost  without  exception  a  history  of  the  condition  having 
begun  in  infancy  or  childhood.  Several  writers,  who  ha\-e 
drawn  conclusions  from  a  small  number  of  cases,  have  been 
struck  by  an  apparent  age-gap  in  the  cases,  and  have  suggested 

5 


66 


CONGENITAL    DILATATION    AND 


that  there  exist  two  types  of  the  condition,  one  occurring  in 
children,  which  is  congenital,  and  another,  occurring  in  old 
people,  which  is  acquired. 

The  following  table,  however,  which  is  based  upon  a  study 
of  one  hundred  collected  cases,  disproves  this  : — 


Ages. 
Under  5 
5  to  10 
10  to  20 
20  to  30 
30  to  40 
40  to  50 
50  to  60 
60  to  70 
Over  70 
Not  stated 


Cases. 

24 
16 

14 
II 


4 
5 

Total     100 


The  greatest  number  of  cases  occur  in  infants,  and  the  numbers 
steadily  decrease  up  to  old  age.  The  condition  is  not  necessarily 
fatal,  and  it  seems  certain  that  those  occurring  in  the  latter 
periods  of  life  are  congenital  cases  which  have  survived. 

The  condition  is  slightly  commoner  in  males  than  in  females, 
being  in  the  proportion  of  three  to  two. 

One  would  expect,  if  the  condition  were  congenital,  that 
associated  congenital  abnormalities  would  be  common,  but 
curiously  enough  this  is  apparently  not  so.  Out  of  one 
hundred  cases  collected  by  the  author,  there  were  only  fifteen 
in  which  there  was  any  other  congenital  abnormality.  In  ten, 
there  was  a  congenital  abnormahty  of  the  anus,  in  two,  a 
congenital  stricture  of  the  colon  ;  two  were  deaf  mutes,  and 
one  an  imbecile. 

Several  writers  have  attempted  to  prove  that  there  is  a 
connection  between  this  condition  and  disease  of  the  central 
nervous  system,  but  there  is  no  evidence  of  this.  The  cases  of 
great  dilatation  of  the  colon  which  are  often  met  with  in  the 
inmates  of  asylums  are  of  an  entirely  different  character,  the 
bowel  wall  being  thin  and  atrophied,  whereas  in  this  condition 
it  is  alwaj^s  hypertrophied.  A  further  argument  against  the 
condition  being  due  to  a  congenital  neuro -muscular  defect  is, 
that  powerful  peristalsis  undoubtedly  occurs  in  the  hypertrophied 
and  dilated  bowel.     Nothnagel,   recognizing  that  hypertrophy 


HYPERTROPHY    OF    THE     COLON         67 

of  the  bowel  wall  is  incompatible  with  a  neuro-muscular  defect, 
has  suggested  that  there  is  such  a  defect  of  congenital  origin 
in  the  lower  part  of  the  large  bowel,  and  that  the  hypertroph\' 
is  a  secondary  effect  occurring  above  it.  There  are,  however, 
no  pathological  data  to  support  this  view. 

The  most  probable  explanation  of  this  very  puzzling  condition 
seems  to  be,  that  there  is  some  congenital  abnormahty  which 
causes  a  partial  or  intermittent  obstruction,  and  that  the 
dilatation  and  hypertrophy  are  secondary  to  this.  In  support 
of  this  view  we  find  that  definite  obstruction  is  present  in  some 
of  the  cases.  Thus,  out  of  the  hundred  cases  already  mentioned, 
obstruction  was  present  in  twenty-three. 

Causes  of  Obstruction.  Cases. 

Congenital  stricture  of  the  rectum  . .  n 

Chronic  vohailus  of  the  sigmoid  flexure  . .  7 

Angulation 

Slight  rectal  narrowing 

Congenital  stricture  of  the  sigmcid  flexure 
No  obstruction  found  . .  . .  . .  77 


Total       100 

Even  when  such  a  condition  as  a  chronic  volvulus  exists, 
however,  this  may  be  a  secondary  consequence  of  the  dilatation , 
and  not  its  cause.  The  fact  remains,  that  in  the  great  majority 
of  cases  no  obstruction  of  any  kind  is  found,  and  also  that  in 
several  the  dilatation  extended  right  down  to  the  anus  or  to 
the  middle  of  the  rectum. 

It  seems  possible  that,  owing  to  some  abnormality  of  the 
mesentery  of  the  sigmoid  flexure,  an  angle  or  kink  forms  in  this 
portion  of  the  bowel  which  causes  obstruction  when  the  patient 
is  in  the  erect  position.  An  obstruction  from  this  cause  would, 
of  course,  not  be  obvious  in  the  recumbent  position,  and  would 
be  undetectable  at  an  operation  or  on  the  post-mortem  table. 
There  are,  however,  three  cases  on  record  in  which  the  colon 
has  again  dilated  after  the  dilated  sigmoid  had  been  resected, 
and  a  straight  passage  left  between  the  end  of  the  descending 
colon  and  the  rectum.  Such  cases  appear  impossible  of 
explanation  at  present.  The  most  remarkable  is  that  reported 
by   Maurice   Richardson.* 

*  Boston  Med.  and  Surg.  Journ.,  Feb.   14,    1901. 


68         CONGENITAL    DILATATION    AND 

Case. — The  patient  was  a  girl  who  had  an  enormous  dilatation  of 
the  sigmoid  flexnre.  The  dilated  sigmoid  loop  was  resected,  and 
the  ends  anastomosed  so  as  to  form  a  straight  passage  from  the 
end  of  the  descending  colon  to  the  rectum.  A  year  and  two  months 
later  the  patient  returned  with  fresh  symptoms  of  obstruction  and 
a  distended  abdomen,  and  on  performing  laparotomy  it  was  found 
that  a  new  coil  of  dilated  bowel  had  formed,  around  the  central 
portion  of  which  the  scar  of  the  original  anastomosis  could  be  seen. 
Not  only  had  the  dilatation  begun  again  here,  but  it  had  reached 
such  dimensions  that  a  new  sigmoid  flexure  had  formed  which 
filled  the  pelvis  and  whole  lower  abdomen.  This  new  dilated  loop 
was  again  excised,  but  a  year  later  the  colon  had  again  dilated  at 
the  same  spot. 

Morbid  Anatomy. 

The  essential  condition  that  is  always  present  is  great 
dilatation  of  the  whole  or  part  of  the  colon,  accompanied  by 
much  thickening  and  hypertrophy  of  the  dilated  portion. 

The  dilatation  is  in  all  cases  enormous,  so  that,  as  a  rule,  almost 
the  entire  abdominal  cavity  is  occupied  by  the  dilated  portion 
of  the  colon,  and  on  opening  the  abdomen  nothing  can  be  seen 
but  the  huge  sac  formed  by  the  dilated  bowel.  The  small 
intestines  are  not  involved  in  the  dilatation,  but  are  usually 
found  pushed  into  the  back  of  the  abdomen  and  collapsed. 

The  bowel  is  not  only  dilated,  but  also  elongated,  which, 
results  in  its  assuming  abnormal  and  often  acute  flexures  and 
kinks.  This  elongation  is,  however,  limited  to  some  extent 
by  the  mesentery,  which  prevents  more  than  a  certain  limited 
amount  of  stretching  in  a  longitudinal  direction  from  taking 
place  on  that  side  of  the  bowel  to  which  it  is  attached.  The 
mesentery  cannot,  however,  limit  the  longitudinal  stretching 
of  the  colon  on  the  side  away  from  its  attachment,  and  as  a 
result  this  side  becomes  elongated  to  a  much  greater  extent  than 
the  mesenteric  side.  The  affected  portion  of  colon  becomes, 
markedly  convex  in  its  longitudinal  axis,  and  assumes  a  shape 
like  that  of  the  stomach,  with  a  lesser  and  a  greater  curvature. 
Thus,  the  dilated  portion  of  the  colon  is  often  spoken  of  as. 
forming  a  huge  pouch,  or  else  as  resembling  the  stomach. 

A  further  result  is  that  the  mesentery  becomes  considerably 
shortened,  as  the  peritoneum  is  separated  by  the  dilatation  of 
the  colon  between  its  layers.  This  shortening,  combined  with 
the  deformity  produced  by  elongation,  causes  the  dilated  bowel 


HYPERTROPHY    OF    THE    COLON 


69 


to  become  much  more  lixed  than  is  normahy  the  case.  The 
immobility  of  the  colon  is  a  well-marked  feature  when  the 
abdomen  is  opened  either  at  an  operation  for  the  relief  of 
the  condition,  or  post  mortem.  The  dilated  bowel  cannot  be 
pulled  up  or  delivered  out  of  the  abdomen,  or  even  moved  about 
to  any  appreciable  extent,  unless  it  is  first  emptied  of  its 
contained  gas.  The  dilated  part  of  the  colon  varies  in  different 
cases.  The  entire  colon,  and  the  rectum  to  an  inch  above  the 
anus,  may  be  affected,  or  only  one  comparatively  short  portion. 


I-'ig^.  26. — Diagram  to  show  the  secondary  results  of  dilatation  of  the  colon.  As  the  colon  becomes 
dilated,  the  mesocolon  is  shortened,  and  as  the  attachment  of  the  mesocolon  (shown  by  the 
black  line)  remains  the  same,  the  elongation  of  the  colon  which  accompanies  dilatation  causes  the 
curvature  of  the  colon  to  be  much  exaggerated.  The  upper  figure  shows  the  normal,  and  the 
lower  the  dilated  bowel. 


In  none  of  the  cases  I  have  collected  have  there  been  two 
separate  and  distinct  dilatations  in  the  same  individual ;  and 
in  none  has  the  small  bowel  been  affected. 

The  part  most  usually  dilated  is  the  sigmoid  flexure  alone  : 
out  of  100  cases,  the  dilatation  involved  the  sigmoid  alone  in 
51,  while  in  33  of  the  remainder  it  was  involved  together  with 
other  portions  of  the  colon. 


CONGENITAL    DILATATION    AND 


Thus,  the  sigmoid  flexure  was  dilated  in  84  out  of  100 
cases :  the  entire  colon  was  dilated  in  20,  and  in  g  of 
these  the  rectum  was  also  involved  in  the  dilatation  ;  the 
transverse  colon  was  the  only  part  dilated  in  2  cases,  while 
it  was  involved  with  other  parts  in  36. 


Parts  of  Colon  Affected. 


Sigmoid  .  . 
Whole  colon 

Hepatic  flexure  to  rectum 
Hepatic  flexure  to  sigmoid 
Splenic  flexure  to  rectum 
Cscum  to  splenic  flexure 
Transverse  colon  .  . 
Descending  colon 


51 
20 
II 

I 
2 

4 
2 
I 


In  some  cases  the  dilatation  begins  and  terminates  abruptly  ; 
but  in  many,  the  transition  from  the  dilated  to  the  normal 
portion  of  the  colon  is  funnel-shaped. 

The  dilatation  of  the  bowel  is  rightly  spoken  of  as  enormous  : 
in  an  infant  thirteen  months  old  the  diameter  of  the  dilated 
portion  of  the  colon  was  5  inches  ;  and  in  a  boy  of  ten  the 
diameter  was  6  inches. 

In  one  of  Dr.  Hawkins's  cases  the  circumference  of  the  dilated 
portion  of  bowel  was  43J  inches.  In  a  case  of  the  author's  the 
diameter  of  the  sigmoid  flexure  was  estimated  to  be  between 
8  and  9  inches. 

It  is,  of  course,  obvious  that  with  such  enormous  dilatation 
and  stretching  of  the  bowel  as  occurs  in  these  cases,  the  ana- 
tomical relationships  of  the  affected  portion  of  bowel  are  entirely 
altered,  so  that  the  apex  of  the  sigmoid  flexure  may  be  found 
to  He  under  the  liver.  In  some  cases  the  thoracic  organs  have 
been  considerably  displaced,  from  the  pushing  up  of  the 
diaphragm  and  the  widening  of  the  angle  of  the  lower  ribs. 

In  addition  to  the  dilatation,  the  bowel  is  also  hypertrophied 
to  a  very  marked  degree,  and  this  is  quite  as  characteristic  of 
the  condition  as  the  dilatation.  The  wall  of  the  dilated  portions 
of  the  colon  is  greatly  thickened,  in  many  cases  being  as  much 
as  a  quarter  of  an  inch  in  thickness,  and  so  tough  that  it  feels 
like  thick  leather. 

The  thickening  extends  to  the  peritoneum  covering  the  bowel, 
but  is  chiefly  found  in  the  muscular  coats.  Both  the  longi- 
tudinal and  circular  fibres    are  hypertrophied,  and   on  cutting 


Fig.  27. — Photograph  of  the  colon  in  Dr.  George  Carpenter's  case  of  congenital  dilatation 
in  a  child  aged  six  months.     ]_Proc.  Roy.  Soc.  Med.,  Dec,  1908,  Vol.  ii..  No.  2,  p.  39.] 


HYPERTROPHY    OF    THE    COLON 


71 


sections  of  the  bowel- 
wall  the  muscle  fibres 
can  be  seen  to  be  in- 
creased both  in  size 
and  in  number. 

The  mucous  mem- 
brane takes  little  if 
any  part  in  the  general 
hypertrophy,  but  there 
is  some  thickening  of 
the  submucosa. 

This  hypertrophy  of 
the  bowel-wall  is  not 
confined  to  the  adult 
cases,  but  is  also  pre- 
sent in  infants  suffer- 
ing from  the  condition. 

In  the  specimen  of 
Dr.  Carpenter's  case, 
illustrated  in  Figs.  27, 
28,  which  was  taken 
from  an  infant  two 
months  old,  the  wall 
of  the  dilated  colon 
was  an  eighth  of  an 
inch  thick,  and  felt 
like  leather. 

Contents  of  the  Di- 
lated Bowel.  —  These 
usually  consist  mainh' 
of  flatus,  but  very  large 
quantities  of  faecal 
material  are  present  if 
the  bowels  have  not 
acted  for  some  time, 
and  it  is  the  accumu- 
lation of  such  material 
in  large  quantities 
which  causes  the  ulti- 
mate acute  symptoms 
in     most    cases.       In 


^^^ 


y^V.'— C 


Fig.  2S. — Microscopic  section  of  the  descending  colon  in  the 

same  case  as  Fig.  27. 
[Froc.  Roy.  Soc.  Med.,  Dec,  iqoS,  Vol.  ii..  No.  2,  p.  3^.] 


72         CONGENITAL    DILATATION    AND 

several  cases  large  faecal  calculi  have  been  found  in  the  dilated 
loop.  In  a  case  recorded  by  Tuppier  there  was  a  calculus 
weighing  three  pounds. 

Secondary  Changes  in  the  Dilated  Loop. — Stercoral  ulceration 
in  the  dilated  loop  sometimes  occurs,  but  is  quite  uncommon  ; 
it  was  onty  present  in  twelve  per  cent  of  the  author's  cases. 
Death  has  resulted  from  perforation  in  a  few  of  the  cases. 

Prognosis. 

Out  of  the  total  cases,  63  died,  and  32  are  stated  to  have 
recovered  ;   the  result  is  unknown  in  5. 

Of  the  cases  said  to  have  recovered,  however,  very  few  have 
been  followed  for  more  than  a  few  months,  so  that  the  mortality 
is  probably  much  higher  than  is  represented  by  these  figures. 

Of  the  cases  not  operated  upon  there  were  45,  and  of  these 
36  died  and  9  recovered.  Among  the  unoperated  cases,  therefore, 
the  mortality  is  very  high. 

In  the  majorit}^  of  cases  death  has  occurred  with  symptoms 
of  intestinal  obstruction  ;  in  some,  from  perforation  and  general 
peritonitis ;  and  in  a  few  it  was  quite  sudden,  from  no 
apparent  cause.  In  one  case  death  occurred  while  an  enema 
was  being  administered,  in  two  while  the  patient  was  in  bed, 
and  in  one  while  the  patient  was  getting  out  of  bed.  In  a  good 
many  cases  it  has  apparently  resulted  from  some  operation 
undertaken  for  the  rehef  of  the  condition. 

Several  of  the  patients  have  died  from  acute  obstruction 
due  to  a  volvulus  of  the  dilated  coil. 

Toxaemia  and  exhaustion,  or  marasmus,  have  been  the  cause 
of  death  in  some  cases,  especially  in  children  and  infants. 

It  is  a  mistake,  however,  to  suppose  that  the  condition  is 
necessarily  fatal  if  left  alone,  for  in  quite  a  number  of  instances 
children  suffering  from  the  condition  have  grown  up  and  reached 
adult  age. 

In  the  author's  collected  cases,  there  were  ten  who  had  lived 
to  over  60  years  of  age.  Usually,  however,  the  condition  proves 
fatal  in  the  first  few  years  of  life. 

Treatment  of   Congenital  Dilatation   and 
Hypertrophy   of    the   Colon. 

Non-operative  Treatment. — The  non-operative  treatment  of 
this  condition  consists  principally  in  getting  the  bowels  to  act 


HYPERTROPHY    OF    THE     COLON 


/  i 


regularly  by  the  administration  of  enemas  and  aperients. 
Aperients  are  usually  of  little  use,  and  enemata  will  have  to  be 
emploj^ed.  Large  enemata,  if  carefully  administered,  will,  in 
some  cases,  keep  the  patient  in  comparative  comfort  ;  but  they 
will  have  to  be  used  daily  in  order  to  prevent  accumulation  of 
faeces  in  the  dilated  bowel.  Large  doses  of  magnesium  sulphate 
will  sometimes  relieve  the  constipation  by  rendering  the  contents 
of  the  colon  fluid.  Intestinal  muscle  stimulants  such  as 
strychnine,  nux  vomica,  and  ergot  may  be  tried,  and  abdominal 
massage  and  application  of  the  galvanic  current  will  often  allay 
the  symptoms  for  a  time. 

When  these  measures  fail,  recourse  must  be  had  to  operation, 
which  in  most  cases  becomes  necessary  sooner  or  later. 

Operative  Treatment. — Whenever  possible,  operation  should 
be  avoided  when  there  are  obstructive  symptoms  and  the 
dilated  bowel  is  loaded  with  solid  faeces.  Every  effort  should 
first  be  made  to  empty  the  bowel  :  even  then  the  dilated  colon 
is  not  easy  to  deal  with,  and  when  loaded  with  many  pounds 
of  semi-solid  faeces  the  greatest  difficulty  may  be  experienced. 

Colotomy. — The  record  of  cases  operated  upon  show  that 
the  mortality  attending  colotomy  for  this  condition  is  very 
high,  higher  in  fact  than  for  any  other  procedure.  Thus,  out  of 
fourteen  cases  treated  by  colotomy,  eleven  died.  This  might  to 
some  extent  be  accounted  for  if  the  colotomv  w'as  done  only  for 
the  relief  of  obstruction  where  acute  symptoms  were  present ;  but 
the  cases  show  that,  even  when  colotomy  was  done  where  no  acute 
symptoms  existed  at  the  time  of  operation,  it  often  proved  fatal. 
Death  occurred  in  most  cases  from  general  peritonitis  following 
the  operation,  and  it  was  found  at  the  post-mortem  examination 
that  the  bowel  had  torn  away  from  the  abdominal  wall,  or 
leaked.  The  reason  for  this  is  obvious  :  an  artificial  anus  made 
into  a  huge  pouch  of  bowel,  such  as  is  usually  present  in  these 
cases,  is  a  very  different  thing  from  an  ordinary  colotomy  operation 
performed  on  normal  bowel.  The  dilated  loop  is  large  and 
heavy,  and  a  very  serious  drag  occurs  upon  the  sutures  uniting 
it  to  the  abdominal  wall.  The  result  is  that  the  colon  usually 
tears  away,  and  causes  general  peritonitis  from  leakage  into 
the  peritoneal  cavity. 

The  formation  of  a  spur  is,  of  course,  impossible,  and  if 
colotomy  has  to  be  done,  it  should  be  by  the  lumbar  route. 

Quite    apart    from   the    fatal    results    which    have    followed 


74         CONGENITAL    DILATATION    AND 

colotomy  in  these  cases,  this  operation  frequently  fails  to  relieve 
the  obstruction.  In  quite  a  number  of  cases  the  bowels  would 
not  act  through  the  colotomy  opening,  and  the  author  has  only 
been  able  to  find  two  in  which  any  benefit  was  obtained  from 
the  operation. 

We  must  conclude  that  colotomy  is  both  a  dangerous  and 
unsatisfactor}'  operation  in  these  cases,  and  should  not  be 
performed  except  for  the  relief  of  urgent  obstruction,  when  the 
bowel  above  the  dilated  portion  should  be  opened  or  lumbar 
colotomy  performed. 

Resection  of  the  Dilated  Portion  of  the  Colon. — This  is  the 
operation  which  has  been  attended  with  the  best  results  in  these 
cases,  and  in  spite  of  the  difficulty  of  resecting  such  enormously 
dilated  bowel,  it  has  not  been  attended  b3i'  a  high  mortality. 

In  aU  but  two  of  the  collected  cases  in  which  this  operation 
was  performed,  the  dilatation  was  confined  to  the  pelvic  colon. 
In  one  case,  however,  the  entire  colon  was  successfully  resected 
for  this  condition. 

In  most  of  the  cases  where  resection  has  been  successful^ 
performed,  the  patient  has  completely  recovered  ;  but  in  at 
least  three  instances  the  dilatation  has  recurred  after  resection. 
In  Dr.  Richardson's  case,  a  second  resection  of  the  dilated  colon 
was  done,  but  the  condition  again  recurred.  Even  resection  of 
the  dilated  bowel  cannot,  therefore,  be  depended  upon  to  cure  the 
condition,  as  some  remaining  portion  of  the  bowel  may  again 
dilate,  and  cause  the  same  sj-miptoms  as  before.  In  those  cases, 
however,  where  the  condition  recurred,  the  portion  in  which  the 
re-dilatation  took  place  included  the  line  of  anastomosis, 
and  this  rather  suggests  that  possibly  if  the  colon  had  in  the 
first  instance  been  more  widely  resected,  there  would  have  been 
no  recurrence. 

When  the  dilatation  is  confined  to  the  sigmoid  flexure, 
resection  of  the  dilated  loop,  going  as  wide  as  possible  of  the 
affected  portion,  seems  to  be  the  best  method  of  treatment. 

When  the  whole  or  the  greater  portion  of  the  colon  is 
invoh'ed,  the  operation  must  be  attended  by  such  difficulties, 
owing  to  the  size  and  fixity  of  the  bowel,  that  it  is  doubtful 
if  it  is  justifiable,  and  a  preliminary  short-circuiting  operation 
is  preferable. 

In  one  case  I  performed  appendicostomy  for  this  condition. 
The  operation  was  done  in  the  hope  of  being  able    to    prevent 


HYPERTROPHY    OF    THE    COLON         75 

accumulation  in  the  enormously  distended  sigmoid  by  washing 
out  the  whole  colon  daily  with  water  through  the  appendix. 
The  patient,  a  man  of  22,  was  quite  well  between  the  attacks 
of  obstruction  from  which  he  suffered,  and  it  did  not  seem 
justifiable  to  subject  him  to  the  danger  of  excision  of  the 
enormous  loop  of  dilated  bowel,  unless  every  other  method 
failed. 

After  the  operation  it  was  found  possible  for  him  to  keep  his 
dilated  sigmoid  practically  empty  by  daily  washing  it  through 
from  the  appendix. 

A  year  after  operation  he  was  still  well.  He  washed  out  the 
colon  daily  through  the  appendicostomy  opening,  and,  although 
during  that  time  there  had  twice  been  considerable  difficulty  , 
in  getting  the  bowels  open,  the  threatened  obstruction  had,  on 
both  occasions,  been  overcome  by  the  injection  of  warm  water 
into  the  caecum. 

It  would  seem  as  if  the  operation  were  well  worth  a  trial  before 
proceeding  to  more  serious  measures. 

Ileo-sigmoidostomy  has  been  performed  in  a  few  cases ;  but, 
although  it  may  afford  temporary  relief,  it  cannot  cure  the 
condition  unless  followed  by  resection  of  the  dilated  loop.  The 
operation  of  narrowing  the  dilated  bowel  by  means  of  Lembert 
sutures,  in  a  similar  manner  to  the  operation  of  gastroplication 
for  the  relief  of  gastric  dilatation,  has  also  been  tried,  but  no 
good  results  have  followed  it.  Fixation  of  the  colon  has 
been  similarly  unsuccessful. 

REFERENCES. 

Keith. — Lond.  Hosp.  Museum  Cat.  Nos.  1238,  1238a,  c,  d,  and  1239. 

Treves. — Intestinal  Obst.  1899,  232. 

LocKwooD. — Brit.  Med.  Jour.  1882,  ii.  574,  and  Barts.Hosp.  Reps.  Vol.  19. 

RoLLESTON. — Path.  Trans.  1891,  122. 

FiTZ. — Amer.  Jour.  Med.  Set.  Aug.,  1889. 

Treves. — Lancet,  1898,  i.  276. 

OsLER. — Johns  Hopkins  Hosp.  Bull.  iv.  30. 

GooDHART. — Clin.  Trans.  1880,  xiv.  84. 

RoLLESTON  and  Hayward. — Trans.  Clin.  Soc.  1896,  xxix.  201. 

FoRMARD. — Annals  of  the  Universal  Med.  Set.  Vol.  i.  93. 

Hirschsprung. — Annals  of  the  Universal  Med.  Sci.  Vol.  i.  1893. 

Jacoby. — Archiv.  Pediatrics,  1893,  Vol.  x.  440. 

WooLMER. — Brit.  Med.  Jour.  1889,  1330. 


76 


Chapter    VII. 
VOLVULUS    OF    THE    COLON. 

By  a  volvulus  we  understand  a  condition  in  which  some  portion 
of  the  colon  has  twisted  upon  itself  or  around  its  mesentery. 
There  are  several  kinds  of  volvulus,  depending  upon  the  part 
of  the  colon  involved,  and  the  nature  and  direction  of  the  twist. 
It  is  obvious  that  volvulus  can  only  occur  where  the  colon 
has  a  mesentery,  and  the  only  part  of  the  colon  which  normally 
possesses  a  mesentery  sufficiently  long  to  allow  the  colon  to 
twist  is  the  pelvic  colon  ;  but  abnormally,  other  portions  of 
the  colon  may  have  a  long  mesentery,  and  then  may  become 
twisted.  Volvulus  forms  about  4  per  cent  of  all  cases  of 
intestinal  obstruction. 

From  a  clinical  standpoint  we  may  divide  the  cases  of  volvulus 
into  acute  volvulus,  in  which  the  twist  forms  suddenly  and  causes 
complete  obstruction  and  strangulation  of  the  involved  gut ;  and 
chronic,  volvulus,  in  which  the  twist  is  not  complete  and  does  not 
cause  strangulation,  though  it  produces  temporary  obstruction. 

Symptoms. 

Acute  Volvulus. — This  is  the  commoner  condition,  and 
the  symptoms  are  those  of  acute  intestinal  obstruction.  They 
usually  commence  quite  suddenly,  with  abdominal  pain  and 
colic.  The  pain  is  often  severe,  and  when  first  seen  the 
patient  is  frequently  doubled  up  in  bed  and  groaning  with 
the  pain,  which  comes  on  in  spasms.  There  is  usually 
absolute  constipation,  but  exceptionally  there  may  be  straining 
and  tenesmus,  with  the  passage  of  small  liquid  stools  and 
mucus.  Vomiting  is  not  a  marked  feature  of  obstruction 
from  this  cause,  and  not  infrequently  is  absent  altogether.  The 
most  marked  feature  of  the  symptoms  is  distention  of  the 
abdomen.  This  occurs  rapidly,  and  soon  reaches  great  dimen- 
sions. The  abdomen  is  tense,  the  diaphragm  pushed  up,  and 
the  respiration  may  be  much  embarrassed.      The  abdomen  is 


VOLVULUS    OF    THE     COLON  ri 

hyper-resonant.  The  distention  usually  is  so  great  that  but 
little  can  be  made  out  in  the  abdomen,  and  it  is  not  possible  to 
locate  the  trouble  to  any  particular  area. 

Another  characteristic  symptom  is  early  and  acute  tenderness 
of  the  abdomen.  Collapse,  with  paleness  of  the  skin  and  a 
feeble  pulse,  occurs  after  the  condition  has  existed  for  some  time, 
but  it  does  not  appear  so  early,  nor  is  it  so  well  marked  as  in 
many  other  forms  of  intra-abdominal  trouble. 

In  those  cases  where  the  caecum  is  involved  in  the  volvulus, 
the  onset  of  the  symptoms  is  usually  somewhat  slower,  and 
vomiting  is  almost  invariably  present. 

As  a  rule  the  pain  in  volvulus  is  more  or  less  correctly  localized 
to  the  area  overlying  the  lesion,  and  this  may  be  used  as  a  guide 
in  diagnosis.  Acute  and  severe  toxaemia  is  usually  present  in 
acute  volvulus,  and  in  the  later  stages  the  patient  presents 
all  the  symptoms  of  acute  poisoning  from  the  contents  of  his 
own  intestine.  The  progress  of  the  case  varies  considerably. 
Occasionally  it  is  very  rapid ;  thus  Mr.  Heath  recently  reported 
a  case  in  which  a  volvulus  of  the  sigmoid  became  completely 
gangrenous  in  thirty  hours,  and  even  more  rapid  cases  of  gangrene 
than  this  have  occurred.  On  the  other  hand,  the  symptoms  of 
volvulus  may  exist  for  several  days,  and  yet  at  the  operation 
the  volvulus  is  not  found  to  be  gangrenous;  the  condition,  of 
course,  depends  on  the  severity  and  tightness  of  the  twist. 

In  volvulus  of  the  ileocaecal  angle  the  symptoms  may  be  very- 
acute  and  death  occur  early,  owing  to  the  large  mass  of 
bowel  which  is  strangulated.  Thus  in  a  case  described  by  Mr. 
Burgess,*  death  occurred  in  sixteen  hours  from  the  onset  of 
symptoms.  The  patient  was  a  boy  aged  8,  in  whom  the 
volvulus  included  the  whole  of  the  intestine,  from  the  duo- 
denum to  the  middle  of  the  ascending  colon. 

Chronic  Volvulus.  —  There  are  usually  recurring  attacks 
of  obstruction,  with  pain  and  constipation.  In  a  typical 
case  the  patient  has  repeated  attacks  of  obstruction  at 
varying  intervals,  which  either  pass  off  after  a  short  time,  or 
are  reheved  by  the  administration  of  an  enema.  During  the 
attacks  the  symptoms  are  often  alarming,  the  abdomen  is  dis- 
tended, the  bowels  will  not  act,  and  there  is  great  pain  in  the 
abdomen.     The  attack,  however,  passes  off,   only  to  recur  at 

*  Lancet,  Dec,  1902. 


78  VOLVULUS    OF 

some  later  period.  In  other  cases  there  are  no  symptoms  of 
acute  obstruction  at  any  time,  but  the  patient  has  attacks  of 
obstinate  constipation  lasting  for  several  days,  when  the  bowels 
refuse  to  act  and  there  is  abdominal  discomfort.  Between  the 
attacks  he  may  be  quite  well,  though  occasionally  there  is  a 
complaint  of  dull  pain  in  the  back  or  in  the  abdomen.  These 
cases  not  infrequently  culminate  in  acute  and  fatal  obstruction. 

In  chronic  volvulus  of  the  caecal  angle,  frequent  and  recurring 
attacks  of  slight  obstruction,  with  vomiting  and  distention,  are 
not  uncommon,  and  in  some  cases  attacks  have  continued  for 
several  years  before  an  acute  and  serious  crisis  necessitating 
operation  has  occurred.  In  some  cases  of  chronic  or  recurring 
volvulus,  the  symptoms  are  very  obscure,  and  it  is  only  as  the 
result  of  an  exploratory  operation  that  the  true  nature  of  the 
condition  is  made  clear.  It  is  probable  that  in  many  of  these 
the  twist  only  occurs  while  the  patient  is  in  the  erect  position. 
Thus  patients  suffering  from  this  condition  sometimes  state 
that  they  can  only  pass  flatus  when  lying  down,  and  the  author 
once  operated  upon  a  patient  who  said  he  was  only  able  to  pass 
flatus  by  going  on  his  hands  and  knees.  There  is  often  great 
difficulty  in  getting  the  bowels  to  act,  and  aperients  are  frequently 
useless.  Enemas,  by  distending  the  bowel  and  so  partly  un- 
twisting it,  often  give  relief  when  aperients  will  not  do  so.  Many 
patients  with  chronic  volvulus  complain  of  a  dragging  pain  in 
the  back  when  standing  or  walking,  and  of  vague  abdominal  dis- 
comfort. Their  symptoms  are  often  indefinite  and  vague,  and  as 
a  result  are  often  quite  unnecessarily  put  down  to  neurasthenia. 

The  diagnosis  is  often  difficult  as  regards  the  cause  of  the 
obstruction  ;  but  volvulus  may  be  suspected  when  in  a  case  of 
acute  intestinal  obstruction  we  find  marked  distention  and  no 
vomiting.  The  patients  are  often  elderly,  and  the  condition  is 
very  rare  in  children  and  young  adults.  It  also  appears  to  be 
more  common  in  men  than  in  women. 

The  cases  in  which  the  csecal  angle  is  involved  may  cause 
great  difficulty  in  diagnosis  ;  and  even  when  the  abdomen  is 
opened,  the  complicated  arrangement  of  the  parts  may  render 
it  almost  impossible  to  ascertain  what  has  occurred. 

Etiology. 

Predisposing  Causes. — i.  Mal-development  of  the  peritoneum 
attaching  the  bowel  to  the  posterior  abdominal  wall,  or  of  the 


THE    COLON 


79 


mesentery.     This  is  the  usual  predisposing  cause  of  compound 
and  caecal  volvuh. 

2.  Alteration  in  the  normal  proportions  between  the  length 
of  the  mesentery  and  of  its  base  of  attachment.  Thus  the 
mesentery  may  be  too  long,  so  that  it  readily  twists  about  its 
base  of  attachment  as  an  axis.  The  elongation  of  the  mesentery 
may  be  congenital  or  acquired.  Or  the  base  of  attachment 
may  be  too  short,  which  produces  a  similar  condition,  and  allows 
the  loop  to  twist  around  its  base.  This  is  a  common  cause  of 
sigmoid  volvulus,  the  shortening  of  the  base  of  attachment 
being  due  to  chronic  inflammation  of  the  mesenterv. 


Fig.  2g. — A  specimen  showing  a  common  mesentery  to  the  csecum  and  ileum.  This  is  a  con- 
genital abnormality  which  predisposes  to  volvulus  of  the  csecal  angle.  The  csecura  has  been 
turned  up      (^After  Alglavc) 


3.  Adhesions  or  contractions  in  the  mesentery  which  draw  it 
into  a  pedicle  and  allow  the  distal  portion  of  the  loop  to  twist 
around  the  narrowed  portion. 

4.  Adhesions  of  part  of  the  colon  to  some  other  portion  of  the 
intestine  or  to  another  viscus  or  structure.  This  may  result  in 
some  other  part  of  the  colon  becoming  twisted  round  the  adherent 
portion  as  an  axis. 

The  predisposing  causes  of  volvulus  may  exist  for  years 
without  causing  obstruction,  and  some  further  or  exciting  cause 
is  necessary  before  serious  symptoms  occur. 


8o 


VOLVULUS    OF 


The  exciting  causes  of  volvulus  are  not  well  known,  and  are 
often  not  evident.  Loading  of  the  bowel  with  fasces,  and  dis- 
tention with  flatus,  may  act  as  exciting  causes  by  forcing  the 
bowel  to  assume  a  fresh  position  in  the  abdominal  cavity. 
Sudden  strain,  and  external  violence,  often  appear  to  act  as 
exciting  causes. 

The  best  examples  of  volvulus  due  to  congenital  abnormalities 
of  the  mesentery  occur  at  the  ileocaecal  angle. 

Elongation  of  the  mesentery  is  a  not  uncommon  cause  of 
volvulus  of  the  sigmoid.     In  some  instances  the  mesosigmoid  is 


/•'ii;.  30. — A  congenital  abnormality  of  the  peritoneum.     The  caecum  i.s  freely  movable,  and  the  last 
few  inches  of  the  ileum  are  fixed.     This  may  result  in  volvulus.     (After  Alglave.) 


congenitally  too  long.  More  usually  the  elongation  has  resulted 
from  overloading  of  the  sigmoid  from  constipation  of  long 
standing,  and  consequent  stretching  of  the  mesosigmoid  from 
the  weight  of  the  loaded  loop. 

In  a  case  recorded  by  Bonuzzi,  the  mesosigmoid  was  four 
times  its  normal  length,  and  in  one  of  my  own  cases  it  was  more 
than  twice  its  normal  length.  In  Bonuzzi's  case,  complete 
volvulus  had  resulted,  while  in  mine  a  partial  volvulus  occurred 
and  caused  intermittent  obstruction.     I  have  been  able  to  find 


THE     COLON  8i 

one  case  of  volvulus  of  the  sigmoid  in  a  child  two  years  and  four 
months  old.  It  seems  probable  that  in  this  patient,  and  the 
two  mentioned  above,  the  elongation  of  the  mesosigmoid  was 
congenital.  In  volvulus  of  the  csecal  angle,  the  abnormality  of 
the  mesentery  is  always  congenital. 

Shortening  of  the  base  of  attachment  of  the  mesentery  has  been 
described  as  congenital  ;  but  there  is  no  proof  of  this,  and  it 
seems  more  probable  that  it  is  always  acquired.  The  usual 
condition  is  one  of  cicatricial  contraction  of  the  peritoneum  from 
chronic  inflammation  in  the  mesosigmoid.  Such  chronic  in- 
flammation is  a  not  uncommon  result  of  constipation.  Bands  of 
thickening  in  the  peritoneum  can  often  be  demonstrated,  or  actual 
adhesions  involving  the  base  of  the  mesosigmoid  can  be  seen. 

Tumours  in  the  mesentery  may  also  cause  shortening,  and 
cases  are  recorded  of  volvulus  occurring  as  the  result  of  a 
lipoma  or  sarcoma  in  the  mesentery.  Glands  which  have 
caseated  and  subsequently  caused  a  cicatrix  are  also  met  with 
as  a  cause  of  volvulus. 

General    Pathology. 

Volvulus  of  the  colon  is  most  common  in  the  sigmoid  flexure. 
Thus  out  of  seventeen  cases  at  the  London  Hospital,  twelve 
were  of  the  sigmoid  flexure,  and  five  of  the  cjecum.  Other 
figures  agree  closely  with  this.  After  the  sigmoid  flexure  the 
commonest  situation  for  volvulus  of  the  colon  is  the  caecum 
or  ileocaecal  angle,  and  this  can  only  occur  as  the  result  of  a 
congenital  abnormahty  of  the  peritoneum.  The  same  applies 
to  volvulus  of  any  other  portion  of  the  colon ;  but  such 
conditions  are  very  rare.  I  have  found  one  case  of  volvulus 
of  the  splenic  angle  which  was  operated  upon  by  Mr.  Little - 
wood.  The  volvulus  consisted  of  the  splenic  flexure,  part 
of  the  transverse  colon,  the  descending  colon,  and  part  of  the 
sigmoid  flexure.  This  portion  of  the  colon  had  a  mesenterv 
five  inches  long.  The  entire  splenic  angle  had  twisted  upon 
itself  and  caused  obstruction  of  the  middle  of  the  transverse 
colon.  Such  cases  must  be  very  rare,  as  I  have  been  unable  to 
find  another  instance.  A  volvulus  of  the  descending  colon  is 
reported  by  Crisp.  The  transverse  colon  is  not  uncommonly 
involved  in  cases  of  compound  and  cscal  volvulus,  but  it  cannot 
become  twisted  on  itself. 

The    varieties    are    verv    numerous,    and    the    most    curious 

6 


82  VOLVULUS    OF 

and  varied   pathological   conditions    are    found.     Two   distinct 
pathological  types  of  volvulus  or  twisting  occur  : — 

(a).  When  the  twist  has  occluded  the  vessels  in  the  pedicle  of 
the  loop  :  that  is,  when  the  blood-supply  to  the  affected  bowel 
is  arrested. 

(b) .  When  the  blood-supply  of  the  affected  loop  is  still  adequate, 
but  the  bowel  lumen  is  partly  or  entirely  obstructed. 

The  affected  loop  of  bowel  (in  condition  a)  becomes  dark  in 
colour,  the  walls  become  oedematous,  and  serum  and,  later, 
blood,  is  exuded  from  the  vessels  into  the  lumen  of  the  bowel,  and 
also  into  the  peritoneal  cavity.  This  exudation  of  blood-stained 
serum  is  due  to  rupture  of  the  finer  capillaries  and  to  intense 
inflammation.  The  affected  loop  also  becomes  greatly  distended 
with  gas,  and  this  is  one  of  the  most  marked  features  of  volvulus. 
The  distention  occurs  very  rapidly,  and  reaches  great  proportions. 
The  gas  causing  the  distention  is  chiefly  carbon  dioxide,  and 
arises  from  the  fermentation  of  the  faecal  contents  of  the  bowel. 
This  gas  is  normally  formed  in  the  bowel,  but  is  absorbed  and 
carried  away  by  the  blood-stream,  and  also  passed  on  by 
peristalsis,  almost  as  fast  as  it  forms.  When  the  blood- 
stream is  arrested,  and  the  bowel  lumen  is  at  the  same  time 
closed,  the  gas  accumulates  in  the  twisted  loop,  and  causes  the 
distention. 

In  the  experiments  which  I  performed  upon  cats  {page  33)  it 
was  found  that  distention  did  not  occur  unless  the  venous  blood- 
stream was  arrested.  If  a  loop  of  the  colon  was  thoroughly 
cleaned  out  with  water  before  it  was  twisted,  or  before  the  blood- 
supply  was  arrested  by  ligature,  distention  did  not  occur,  though 
the  phenomena  of  strangulation  did.  This  proves  that  the 
formation  of  gas  is  not  due  to  the  strangulation,  but  is  simply 
the  result  of  fermentation  of  the  faecal  contents,  and  that  the 
distention  results  from  unrestrained  fermentation  in  the  affected 
loop,  the  gas  so  formed  not  being  absorbed  by  the  blood  or  being 
able  to  pass  into  other  parts  of  the  bowel.  The  pathological 
changes  which  occur  in  complete  volvulus  (condition  a)  differ 
in  no  important  respect  from  ordinary  strangulation,  such  as 
occurs  in  strangulated  hernia.  The  probable  reason  that  dis- 
tention is  more  marked  in  the  case  of  volvulus  is  that  fermentation 
more  readily  occurs  in  the  colon.  The  conditions  for  bacterial 
action  in  the  colon  are  aerobic,  while  in  the  greater  part  of  the 
small   intestine    they   are   anaerobic.     Gangrene    of   the   bowel 


THE    COLON  83 

ultimately  occurs,  and  general  peritonitis  may  be  the  cause  of 
death. 

In  partial  volvulus  (condition  h),  the  pathological  conditions 
are  the  same  as  in  other  forms  of  obstruction  of  the  colon  where 
strangulation  is  not  present.     Distention  is  not  a  marked  feature. 

Violent  peristalsis  occurs  above  the  twist,  and  a  certain  amount 
of  distention  with  faeces  and  gas  in  the  bowel  above.  If  the 
partial  volvulus  is  intermittent  and  lasts  for  a  long  time,  hyper- 
trophy of  the  bowel  above  will  take  place,  as  in  the  case  of  any 
other  form  of  partial  obstruction. 

Volvulus  of  the  Pelvic  Colon- — This  is  the  commonest 
form  of  volvulus.  The  predisposing  cause  in  most  cases  is 
elongation  of  the  pelvic  mesocolon  from  chronic  overloading  of 
this  portion  of  the  bowel,  as  commonly  occurs  in  constipation. 
Meso-sigmoiditis,  with  contraction  and  narrowing  of  the  mes- 
entery, is  a  not  uncommon  contributory  cause.  The  twist  may 
occur  in  either  direction,  but  the  commonest  is  the  clockwise 
direction  with  the  rectum  behind  the  upper  limb  of  the  loop. 
The  distention  of  the  twisted  loop  rapidly  becomes  extreme, 
and  the  sigmoid  may  fill  the  entire  abdominal  cavity,  and  even 
displace  the  thoracic  organs. 

Rupture  of  the  loop  rarely  occurs,  but  haemorrhages  into  it 
are  common,  and  after  a  day  or  two  micro-organisms  apparently 
pass  through  the  bowel  wall  of  the  volvulus  and  cause  septic 
infection  of  the  peritoneum.  Volvulus  of  the  sigmoid  flexure 
sometimes  occurs  in  association  with  congenital  dilatation  of 
the  colon,  but  this  has  already  been  referred  to. 

Volvulus  of  the  pelvic  colon  is  usually  considered  a  condition 
of  late  life  ;  but  I  have  met  with  one  case  in  a  child  aged  two 
years  and  four  months. 

Volvulus  of  the  Csecum  and  Ascending  Colon  (caecal 
angle). — Several  varieties  of  this  form  of  volvulus  have  been 
described,  but  the  only  difference  is  in  the  length  of  the  loop. 
It  can  only  occur  if  the  caecum  possesses  a  mesentery,  and  the 
parts  involved  in  the  volvulus  will  depend  upon  the  length  and 
attachments  of  this  mesentery. 

Several  drawings  are  given  of  abnormal  arrangements  of  the 
peritoneum  covering  the  caecum  and  ascending  colon  {Figs.  29 
and  30),  and  it  will  be  seen  that  any  condition  may  occur  between 
that  of  a  caecum  having  a  short  mesentery,  and  one  in  which  the 
caecum,  ascending  colon,  and  part  of  the  transverse  colon  have 


84  VOLVULUS    OF 

a  common  mesentery  with,  the  whole  of  the  small  bowel.  In  the 
former  case  the  caecum  alone  may  become  twisted  upon  the 
termination  of  the  ileum  and  the  commencement  of  the  ascending 
colon ;  in  the  latter,  the  caecum,  ascending  colon,  and  ileum 
may  become  twisted  around  the  transverse  colon  and  jejunum 
or  duodenum.     There  are  examples  of  both  these  conditions. 

Usually  the  twist  occurs  around  the  ileum  as  an  axis,  the 
heavier  and  larger  portion  of  the  bowel  twisting  round  the 
smaller  and  lighter.  In  Dr.  Whipham's  case,  the  entire  small 
bowel,  together  with  the  caecum  and  ascending  colon,  had  twisted 
round  the  jejunum.  In  another  case  the  caecum,  ascending  colon, 
and  transverse  colon  had  twisted  round  the  ileum. 

The  twist  may  occur  in  either  direction,  but  the  com- 
monest condition  seems  to  be  from  left  to  right.  By  this  I 
mean  in  the  anti-clockwise  direction,  the  caecum  passing 
behind  the  mesentery  and  from  the  right  to  the  left  side  of  the 
abdomen. 

In  speaking  of  the  development  of  the  colon,  I  mentioned 
that,  in  the  earliest  stages,  the  whole  alimentary  canal  possessed 
only  one  straight  mesentery  or  peritoneal  attachment  to  the 
posterior  abdominal  wall.  This  primitive  condition  is  found  in 
the  three-months  foetus,  and  also  in  some  of  the  lower  primates 
(notably  Lemur  coronatus).  At  first,  this  single  mesentery  lies 
vertically  in  the  median  line,  and  the  alimentary  canal  is  a  single 
straight  tube  from  one  end  of  the  body  to  the  other.  Very 
rapidly,  however,  the  alimentary  canal  lengthens,  and  in  so 
doing  becomes  thrown  into  folds.  At  the  same  time  new 
peritoneal  connections  or  attachments  are  formed  between 
these  folds  and  the  posterior  abdominal  wall. 

The  caecum  passes  across  to  the  right  flank,  and  later,  down- 
wards into  the  right  iliac  fossa  ;  at  the  same  time  it  loses  its 
original  mesentery  and  becomes  fixed  in  the  right  iliac  fossa  in 
the  condition  normally  found  in  man.  There  do  not  appear  to 
be  any  cases  in  which  the  early  primitive  condition  has  persisted 
in  its  entirety, — that  is  to  say,  where  the  whole  colon  shares 
a  common  mesenter}^  with  the  small  bowel.  But,  rarely, 
the  caecum,  ascending,  and  part  of  the  transverse  colon,  are 
found  to  have  a  common  mesentery  with  the  whole  of  the  small 
bowel  up  to  the  duodenum. 

It  is  quite  obvious  that  when  this  arrangement  of  the  mesentery 
persists  as  a  congenital  abnormality,  there  is  alwa3's  a  possibility 


THE    COLON  85 

of  the  large  mass  of  bowel  which  is  suspended  from  a  single  and 
comparatively  narrow  mesenteric  attachment  becoming  twisted 
around  its  axis  and  causing  a  volvulus.  That  it  does  not  always 
so  result  is  shown  by  the  fact  that  this  condition  of  the  mesentery 
is  sometimes  found  post  mortem  in  elderly  patients  dying  from 
other  diseases. 

The  pathological  condition  presented  in  these  cases  of  volvulus 


/•"ig.  31. — Diagram  showing  the  condition  present  when  there  is  a  common  mesentery  to  the 
ileum  and  the  right  side  of  the  colon.  Volvulus  is  liable  to  occur,  the  twist  taking  place  round 
the  point  marked  X- 

of  the  caecal  angle  is  often  most  complex.  iVs  a  rule  an  operation 
is  performed  for  the  relief  of  intestinal  obstruction,  and  on 
opening  the  abdomen  the  caecum  is  found  not  to  be  in  its  normal 
position.  The  position  varies  considerably ;  most  commonly  it 
is  found  somewhere  on  the  left  side  of  the  abdomen,  either  below 
the  stomach  or  over  the  left  kidney  :  it  will  depend  upon  the 
length  of  the  adventitious  caecal  mesentery  and  upon  the 
extent  of  the  twist. 


86  VOLVULUS    OF 

The  most  noticeable  thing  on  examining  the  abdominal  cavity 
is  the  complete  emptiness  of  the  right  iliac  fossa,  and  it  is  this 
which,  as  a  rule,  first  draws  attention  to  the  nature  of  the  con- 
dition. The  axis  of  the  twist  is  usually  the  small  bowel ;  but 
the  part  concerned  depends  upon  the  degree  of  abnormality  of 
the  peritoneum  present.  Thus  the  ileum  may  form  the  axis  of 
rotation,  or  it  may  be  the  jejunum,  and  in  two  cases  the  duodenum 
formed  the  axis  of  the  volvulus. 

Where  the  complete  condition  exists,  the  twist  occurs  around 
the  base  of  attachment  of  the  common  mesentery,  the  duodenum, 
and  the  centre  of  the  transverse  colon  :  the  actual  axis  is  usually 
the  superior  mesenteric  artery,  which  here  passes  forward  between 
the  layers  of  the  mesentery,  and  which  supplies  practically  the 
whole  area  of  bowel  forming  the  volvulus.  In  most  cases 
the  rotation  is  in  an  anti-clockwise  direction  (as  looked  at  from 
below),  i.e.,  the  ileum  passes  forward  and  to  the  right,  while  the 
caecum  passes  backwards  and  to  the  left.  The  twist  very  rarely 
occurs  in  the  opposite  direction.  A  reference  to  the  diagram 
will  at  once  show  why  the  rotation  is  usually  in  the  former 
direction.  When  the  parts  are  lying  in  their  normal  position 
and  no  volvulus  has  occurred,  it  will  be  seen  that  a  half-twist 
in  the  anti-clockwise  direction  already  exists  ;  so  that  an 
accidental  half-twist  in  that  direction  will  cause  a  volvulus  of 
the  entire  loop,  while  a  similar  half-twist  in  the  opposite  direction 
will  simply  undo  the  normal  half-twist. 

In  order,  therefore,  for  this  condition  to  occur  from  a  twist  in 
the  clockwise  direction,  the  loop  of  bowel  would  have  to  twist 
through  a  circle  and  a  half,  while  to  produce  a  volvulus  in  the 
opposite  direction  it  will  have  to  rotate  through  half  a  circle 
only.  The  probabilities,  therefore,  are  much  greater  of  a 
volvulus  being  produced  in  one  direction  than  in  the  other. 

In  only  two  of  the  twenty-nine  cases  I  have  collected  was  the 
twist  in  a  clockwise  direction.  In  eighteen  of  the  twenty-nine 
cases  there  was  a  common  mesentery  to  the  whole  of  the  ileum, 
caecum,  ascending  colon,  and  part  of  the  transverse  colon.  In 
seven  cases  the  caecum  had  a  mesentery,  and  was  free  to  move 
about.  In  three  the  caecum  and  ascending  colon  had  a  long 
mesentery. 

In  one  case  there  was  a  compound  volvulus  resulting  in  a  most 
complicated  condition.  The  sigmoid  flexure  was  twisted  round 
the  ileum,  caecum,  and  ascending  colon  from  left  to  right.     One 


THE    COLON  87 

would  suppose  that  this  form  of  volvulus,  owing  to  its  congenital 
origin,  would  occur  most  frequently  in  children  and  infants, 
but  this  is  apparently  not  so.  Most  of  the  cases  are  in  adults, 
and  the  condition  is  most  frequent  between  the  ages  of  twenty 
and  forty. 

The  following  table  shows  the  age  incidence  in  twenty-seven 
cases.  There  were  three  cases  in  infants,  the  youngest  being 
four  days  old,  while  the  oldest  patient  was  seventy-two  : — 


Cases. 
Under  5  years  of  age  . .  . .  . .  3 

Between  5  and  20 
Between  20  and  40 
Between  40  and  60 


Over  60 

The  average  age  was  31 


6 

10 

5 

3 


If  there  is  a  common  mesentery  to  the  ascending  colon,  caecum, 
and  small  bowel,  the  condition  of  the  patient  when  volvulus 
occurs  is  a  very  serious  one,  owing  to  the  great  length  of  the 
bowel  involved  in  the  twist. 

Compound  Volvulus. — Many  of  the  cases  of  cascal  volvulus 
in  which  the  ileum,  caecum,  and  ascending  colon  were  involved, 
have  been  described  as  compound.  But  if  the  term  is  to  be 
retained,  it  should  be  reserved  for  cases  in  which  either  two 
separate  and  distinct  twists  have  taken  place  in  different  portions 
of  the  bowel,  as,  for  instance,  where  there  is  a  volvulus  in  the 
small  bowel  and  another  in  the  sigmoid,  or  where  a  portion  of 
the  small  intestine  has  become  twisted  round  the  sigmoid  flexure, 
or  vice  versa.  Karl  Richter  has  recorded  three  cases  in  which 
there  was  a  volvulus  of  the  small  intestine  and  another  of  the 
sigmoid  flexure.  The  small  intestine  may  become  twisted  round 
the  sigmoid  flexure,  but  more  commonly  the  former  acts  as  the 
axis  and  the  sigmoid  is  twisted  round  it. 

Leichenstein  collected  twenty-one  cases  of  this  form  of  com- 
pound volvulus.  In  twelve  of  these  the  loop  of  small  intestine 
formed  the  axis,  and  the  sigmoid  was  twisted  round  it  from  left 
to  right,  and  from  before  backwards.  In  the  remaining  cases 
the  sigmoid  was  twisted  round  the  small  intestine  in  the  opposite 
direction. 

Treatment. 

In  cases  of  acute  or  complete  volvulus,  immediate  operation 
affords  the  only  hope  of  saving  the  patient's  life,  and  much  of 


88  VOLVULUS    OF 

the  success  of  the  operation  depends  upon  its  being  performed 
as  soon  as  possible  after  the  occurrence  of  the  twist.  Volvulus 
cannot  always  be  diagnosed  apart  from  operation,  but  we 
can  always  diagnose  the  presence  of  acute  obstruction,  and 
this  is  sufficient  indication  for  immediate  operation. 
!  The  abdomen  must  be  opened,  and  the  distended  loop  pulled 
out.  Although  it  is  excellent  practice  when  operating  upon  the 
abdominal  viscera  not  to  expose  the  gut  more  than  is  absolutely 
necessary — and  this  is  particularly  advisable  in  acute  cases — at 
the  same  time,  directly  a  volvulus  has  been  detected  it  is  useless 
to  attempt  to  deal  with  it  inside  the  abdominal  cavity  through 
a  small  incision.  A  free  opening  should  be  made  and  the  entire 
involved  loop  pulled  out.  This  is  more  especially  necessary  in 
dealing  with  volvulus  of  the  csecal  angle,  or  compound  volvulus, 
for  these  are  so  complicated  that,  if  a  big  incision  is  not  made 
and  the  whole  mass  brought  out,  it  is  more  than  probable  the 
reduction  of  the  twist  will  be  incomplete. 

The  distended  loop  or  loops,  having  been  delivered,  must  next 
be  unravelled,  and  the  colon  carefully  examined  to  make  certain 
that  the  obstruction  has  been  completely  removed.  If  the 
volvulus  has  only  existed  a  few  hours,  it  will  probably  be  safe  to 
return  it  and  close  the  abdomen.  If,  however,  there  is  much 
distention,  or  if  it  has  existed  for  more  than  a  few  hours,  the  coil 
must  be  emptied  of  its  contents,  and  drained  b}^  establishing 
an  artificial  anus.  This  is  rendered  necessary  by  the  fact  that 
the  twisted  coil  almost  certainly  contains  highly  virulent  patho- 
genic organisms  and  toxins,  and  its  walls  are  allowing  these  to 
pass  into  the  circulation,  and  also  into  the  peritoneal  cavity. 
The  bowel  is,  moreover,  at  any  rate  temporarily,  paralyzed  :  if 
it  is  simply  untwisted  and  returned,  many  of  the  patients  will 
die  within  the  next  forty-eight  hours  from  intense  toxaemia  or 
peritonitis.  If  possible  the  distended  loop  should  be  washed 
out,  and  a  Paul's  tube  tied  into  it  to  allow  of  the  contents 
draining  freely  away. 

Nothing  more  can  be  done  at  the  first  operation  ;  but  if  the 
patient  recovers,  the  advisability  of  performing  another  operation 
to  prevent  recurrence  should  be  considered,  because  the  pre- 
disposing cause  of  the  volvulus  is  still  present,  and  a  recurrence 
is  very  probable  if  nothing  further  is  attempted. 

It  is  difficult  to  trace  cases  of  volvulus  in  order  to  ascertain  if 
recurrence   has   occurred   in   those  cases   where  the   bowel  has 


THE    COLON  89 

simply  been  untwisted  ;  most  writers,  however,  agree  that  it  is 
common,  and  I  have  been  able  to  find  several  cases  in  which 
the  after-history  showed  recurrence  to  have  taken  place. 

One  patient,  a  man  aged  21,  had  a  volvulus  of  the  sigmoid. 
This  was  untwisted  and  colotomy  performed.  He  recovered,  and 
the  colotomy  opening  closed.  Two  years  later,  he  again  got  a 
volvulus  of  the  sigmoid  flexure  :  on  this  occasion  the  sigmoid 
was  resected,  and  he  remained  well. 

In  another  case,  that  of  a  man  aged  63,  with  volvulus  of  the 
sigmoid,  the  volvulus  was  untwisted  and  the  colon  fixed  by 
forming  an  artificial  anus.  The  patient  recovered,  and  the 
opening  was  allowed  to  close.  A  year  later  the  volvulus 
recurred,  and  at  the  operation  the  adhesions  were  found  to  have 
entirely  disappeared.  The  sigmoid  was  again  untwisted. 
Eleven  months  later  he  had  for  the  third  time  to  be  operated 
upon  for  a  volvulus  of  the  sigmoid. 

Methods  of  Preventing  Recurrence. — Various  operations 
have  been  advised  in  order  to  prevent  a  recurrence  of  the 
volvulus.  Braun  suggested  stitching  the  loop  to  the  abdominal 
wall,  or  in  the  case  of  the  sigmoid,  to  the  iliac  fossa. 

Senn  in  two  cases  shortened  the  mesentery  by  folding  it  upon 
itself  in  a  direction  parallel  to  the  bowel,  and  sutured  the  apex 
of  the  loop  to  the  root  of  the  mesentery.  He  stated  that  no 
recurrence  occurred  in  either  of  these  cases.  One  would  suppose 
that  the  formation  of  an  artificial  anus,  and  the  adhesions  result- 
ing from  this  procedure,  would  be  an  efficient  preventive  of 
recurrence  of  the  volvulus  ;  but  this  is  not  so,  as  the  cases  just 
quoted  prove. 

Similarly,  fixation  of  the  loop  by  sutures  to  the  abdominal 
wall  or  iliac  fossa,  as  suggested  b_\-  Braun,  is  useless  ;  it  could 
hardly  be  as  effective  as  the  formation  of  an  artificial  anus, 
and,  moreover,  in  three  cases  where  this  was  done,  recurrence 
occurred  a  year  later. 

Shortening  of  the  mesosigmoid  offers  a  better  prospect,  but 
the  best  method  of  preventing  recurrence,  and  probably  the  only 
certain  one,  is  excision  of  the  sigmoid  loop.  This  may  be  done 
at  the  time  of  the  first  operation  if  Paul's  method  is  adopted  of 
resecting  the  bowel  and  tying  a  Paul's  tube  into  either  end.  If 
this  is  not  considered  advisable  at  the  time  of  the  first  operation , 
a  second  should  be  done  after  the  patient  has  recovered  from 
the  obstruction,  and  the  loop  excised.     The  ends  may  either  be 


90  VOLVULUS    OF 

united  end  to  end,  or  brought  out  and  the  spur  divided  later 
with  an  enterotome. 

Treatment  when  the  Colon  is  Gangrenous. — If  the 
volvulus  is  found  to  be  gangrenous,  excision  is  the  only  remedy, 
and  the  best  chance  of  recovery  will  be  secured  by  tying  a 
Paul's  tube  into  each  end  of  the  colon  after  resection,  and 
bringing  the  ends  out. 

Treatment  of  Volvulus  of  the  C^cal  Angle. — This 
operation  is  much  more  difficult  than  in  the  case  of  the  sigmoid, 
owing  partly  to  the  fact  that,  as  a  result  of  the  obstruction 
being  higher  up  and  involving  a  large  amount  of  bowel,  the 
patient  is  probably  more  acutely  ill,  but  chiefly  to  the  very 
complicated  condition  of  affairs  that  is  found  on  opening  the 
abdomen,  and  the  difficulty  of  ascertaining  exactly  what  has 
happened. 

The  greatest  difficulty  may  be  experienced  in  untwisting  the 
bowel,  and  the  operation  necessarily  takes  some  time. 

Of  the  twenty-nine  cases  collected  by  the  author,  seventeen 
were  operated  upon.  In  two,  nothing  was  done  beyond  opening 
the  abdomen  and  closing  it  again  ;  both  died.  The  following 
table  shows  what  was  done,  and  the  result,  in  the  remaining 
fifteen  cases  : — 


CASES. 

DIED. 

RECOVERED. 

Untwisting  of  volvulus    . 

9 

5 

4 

Enterostomy 

5 

5 

— 

Excision 

I 

— 

I 

Total      15  10  5 

It  will  be  seen  that  out  of  the  total  seventeen  cases,  only  five 
recovered.  In  two  of  the  cases  in  which  the  volvulus  was 
untwisted,  it  was  found  post  mortem  that  reduction  had  been 
incomplete.  Enterostomy  is  evidently  useless,  as  all  the  cases 
so  treated  died,  and  it  is  necessary  to  untwist  or  excise  the 
volvulus  if  the  patient  is  to  have  any  chance  of  recovery. 

Excision  is  a  formidable  operation  in  such  cases  as  these,  as 
the  patient  is  dangerously  ill  already,  and  a  considerable  length 
of  bowel  will  have  to  be  removed.  In  some  cases  it  would  be 
impossible,  since  it  would  involve  removal  of  the  greater  part 
or  even  the  whole  of  the  small  bowel. 

A  case  has  been  recorded  in  which  the  twisted  loop  was 
gangrenous  and  80  cms.   of  bowel  were  resected,   the  patient 


THE    COLON 


91 


recovering.  This  case  is  a  remarkable  one,  and  shows  that 
excision  is  justiiiable,  even  when  deahng  with  such  a  severe 
lesion  as  a  gangrenous  volvulus  of  the  caecal  angle  of  the  colon. 
Treatment  of  Chronic  Volvulus. — ^This  condition  does  not 
call  for  treatment  because  there  is  acute  obstruction,  and  it  can 
seldom  be  diagnosed  with  certainty  without  opening  the 
abdomen.  It  is  very  unlikely  that  a  volvulus  will  be  found  at 
the  operation  ;  but  a  careful  examination  will  reveal  an  abnormal 
condition  of  the  mesocolon  allowing  a  partial  or  complete  twist 
of  the  colon  to  take  place. 


Fig.  32. — Diagram  showing  method  of  shortening  the  mesocolon  by  Leinbert  sutures.  The 
stitches  pass  through  the  outer  peritoneum  only,  so  as  not  to  constrict  the  vessels.  The  method 
of  passing  additional  sutures  in  order  to  remove  a  kink  is  also  shown. 


The  most  effectual  means  of  dealing  with  the  condition  is  to 
get  rid  of  the  loop  of  colon  by  excision  and  end-to-end  anasto- 
mosis. This  is,  however,  a  somewhat  serious  operation,  and  a 
good  result  may  often  be  obtained  by  measures  involving  less 
risk.  Since  the  condition  is  in  most  cases  due  to  a  deformity 
of  the  mesentery,  the  indication  is  to  correct  this,  and  the 
procedure  which  has  most  to  recommend  it  is  to  shorten  the 
mesocolon  by  means  of  suitably  placed  sutures. 

Another  method  which  is  sometimes  used  is  to  anchor  the 
apex  of  the  loop  to  the  parietal  peritoneum  by  means  of  sutures  ; 
but  while  this  may  succeed  in  the  case  of  the  caecal  angle,  it  is 


92  VOLVULUS    OF    THE    COLON 

more  than  likely  to  fail  when  the  sigmoid  flexure  is  involved, 
owing  to  the  weight  of  this  part  of  the  colon  w^hen  filled  with 
solid  fseces  causing  the  adhesions  to  tear  away. 

Operation  for  Shortening  the  Mesocolon. — The  loop  of 
bowel  forming  the  volvulus  is  drawn  out  of  the  abdominal 
wound,  and  held  towards  the  inner  side  of  the  wound  by 
an  assistant,  so  as  to  put  the  mesocolon  slightly  on  the 
stretch.  A  row  of  Lembert  sutures  are  then  inserted,  taking 
up  the  peritoneum  only,  right  across  the  mesocolon  to  within 
a  short  distance  of  the  bowel  on  each  side.  These  sutures 
should  be  inserted  on  the  outer  or  iliac  side  of  the  mesocolon, 
and  when  inserting  them,  care  should  be  taken  to  avoid  injuring 
any  blood-vessels.  When  this  row  of  sutures  is  tied,  it  should 
form  a  pleat  in  the  mesocolon.  A  second  similar  row  of  sutures 
is  then  inserted  over  the  first,  so  as  to  shorten  still  further  the 
mesentery,  and  if  necessary  a  third  row.  After  the  sutures 
have  been  inserted  it  will  be  found  that  a  kink  has  been  formed 
in  the  colon  at  either  end  of  the  suture  line.  To  get  rid  of  this 
a  few  more  Lembert  sutures  should  be  inserted  parallel  to  the 
bowel  wall  and  opposite  any  such  kink  (see  Fig.  32).  If  the 
sutures  are  property  placed  the  kink  can  be  straightened  out. 
It  is,  of  course,  necessary  to  see  that  the  blood-supply  of  the 
loop  has  not  been  interfered  with  by  the  suturing,  but  if  the 
stitches  have  been  carefully  placed  there  should  be  no  difficulty. 

In  one  patient  on  whom  I  performed  this  operation,  the  meso- 
colon was  over  eight  inches  long,  and  was  reduced  to  three  and 
a  half  inches  by  the  suturing.  Previous  to  operation  he  had 
suffered  severely  from  constipation,  and  could  only  relieve  his 
bowels  by  means  of  large  enemata.  Afterwards  the  bowels 
acted  normally,  and  the  result  was  excellent. 

REFERENCES. 

Hutchinson. — Clin.  Jour.  June  5,   1907. 

TuTTLE. — New  York  Med.  Jour.  Mar.   14,  1908. 

Delatour. — Annals  of  Surg.  Nov.  1905. 

Handfield- Jones. — Med.  Times  and  Gaz.  Jan.  6,  1872. 

Fagge. — Guy's  Hasp.  Reps.  Vol.  xiv. 

Leroque. — Annals  of  Surg.  Nov.   1906. 

Littlewood. — Lancet,  Feb.   18,  1899. 

Firth. — Brit.  Med.  Jour.  1882,  Vol.  ii.  166. 


93 


Chapter  VIII. 

ADHESIONS    AND     KINKING     OF     THE     COLON. 

ADHESIONS     OF     THE     COLON. 

Cases  in  which  there  are  adhesions  involving  the  colon 
are  of  considerable  interest,  for  this  condition  is  a  not 
uncommon  cause  of  severe  constipation  and  abdominal  pain, 
and  occasionally  even  of  acute  obstruction.  The  condition 
commonly  results  in  a  severe  degree  of  chronic  invalidism,  and 
as  such  merits  close  attention. 

In  some  patients  there  are  only  a  few  adhesions,  fixing  or 
kinking  the  colon  at  one  place,  while  in  others  the  adhesions  are 
extensive  and  general,  involving  the  whole  or  a  great  part  of 
the  large  bowel,  and  often  the  small  intestine  as  well. 

Where  there  is  only  a  single  band  of  adhesions,  the  condition 
is  usually  the  result  of  some  local  inflammatory  lesion  such  as 
an  ulcer  of  the  colon,  inflamed  glands,  etc.  ;  but  where  they 
are  extensive  it  has  arisen  from  a  general  peritonitis  or  from 
some  previous  operation  or  injury.  Cases  are  met  with,  how- 
ever, where  no  satisfactory  explanation  of  the  presence  of 
adhesions  can  be  found. 

Baisch  conducted  some  experiments  upon  animals  to  ascertain 
the  cause  of  the  formation  of  adhesions  after  operation.  He 
did  two  series  of  experiments,  in  both  of  which  similar  peritoneal 
lesions  were  produced.  In  one  series,  complete  haemostasis 
was  secured  ;  in  the  other,  varying  quantities  of  blood  were 
allowed  to  remain  in  the  abdominal  cavity.  In  the  first  series 
no  adhesions  developed,  while  in  the  second  they  were  constantly 
present  when  the  animals  were  killed. 

When  a  patient  recovers  from  general  peritonitis,  extensive 
adhesions  between  the  different  parts  of  the  bowel  and  between 
these  and  the  abdominal  walls  are  undoubtedly  left  ;  but  there 
is  abundant  evidence  to  show  that  in  course  of  time  these  may 
entirely  disappear.  Numerous  cases  have  been  recorded,  where 
the  abdominal  cavity  has  been  subsequently  opened  either  at  an 


94  ADHESIONS    AND     KINKING 

operation  or  post  mortem  (the  patient  having  previously  suffered 
from  general  septic  peritonitis),  and  no  trace  of  adhesions  has 
been  found.  In  some  cases,  however,  the  adhesions  do  remain 
after  recovery  from  general  peritonitis,  and  may  cause  serious 
consequences. 

Why  adhesions  should  remain  in  some  cases  and  not  in  others 
cannot  be  explained  until  we  know  much  more  than  at  present 
as  to  the  exact  physiological  processes  which  occur  in  the 
abdomen  during  recovery  from  peritonitis. 

Some  of  the  worst  cases  of  general  adhesions  are  those  in 
which  the  condition  has  followed  an  operation  upon  the  abdomen, 
and  in  which,  apparently,  the  wound  remained  aseptic.  Here 
it  is  probable  that  the  result  is  due  to  blood  having  been 
left  in  the  abdominal  cavity.  Extensive  adhesions  involving  the 
transverse  colon  may  result  from  a  gastric  ulcer,  and  the 
following  case  was  probably  of  this  nature  : — 

Case. — Mrs.  R.  was  under  my  care  in  St.  Mark's  Hospital.  She 
was  sent  to  me  by  her  doctor  on  account  of  repeated  attacks  of 
chronic  obstruction,  accompanied  by  severe  abdominal  pain  and 
symptoms  of  chronic  colitis.  These  symptoms  had  persisted  for 
about  four  years,  and  in  spite  of  treatment  the  attacks  were  becoming 
more  severe  and  frequent.  It  was  thought  probable  that  she  had 
some  obstructing  lesion  of  the  colon,  and  an  exploratory  laparotomy 
was  decided  upon.  On  opening  the  abdomen,  I  discovered  most 
extensive  adhesions  attaching  the  stomach  and  transverse  colon  to 
the  anterior  abdominal  wall.  The  adhesions  were  so  tough  that 
they  could  not  be  separated,  and  I  performed  appendicostomy 
with  the  object  of  preventing  accumulation  in  the  colon,  and  so 
relieving  her  symptoms.  It  seemed  probable  that  the  condition 
had  resulted  from  a  perforated  gastric  ulcer  some  years  previously, 
which  had  produced  a  local  peritonitis.  Subsequent  enquiry 
elicited  a  history  supporting  this  view.  As  a  result  of  the  operation 
there  have  been  no  further  attacks  of  partial  obstruction,  but  she 
still  suffers  at  times  from  abdominal  pain  and  discomfort. 

Symptoms. 

The  symptoms  produced  by  adhesions  of  the  colon  are 
numerous  and  varied.  The  most  common  are  abdominal 
pain  and  discomfort,  and  chronic  difficulty  in  getting  the 
bowels  to  act. 

The  pain  is  often  of  a  most  indefinite  character,  and,  although 
seldom  severe,  is  usually  more  or  less  constant.     It  is  worse 


OF    THE    COLON 


95 


when  standing  or  walking,  and  is  relieved  by  lying  down.  The 
patient  often  refers  the  pain  to  one  or  more  definite  spots  on 
the  abdominal  wall,  but  these  do  not  necessarily  correspond  to 
the  situation  of  the  lesion.  The  pain  may  be  described  as  a 
chronic  dragging  pain,  or  as  a  dull  colicky  pain  ;  it  may  be 
referred  to  the  spine  or  sacral  region.  In  some  cases  there  is 
no  actual  pain,  but  a  constant  sense  of  discomfort  in  the 
abdomen,  only  relieved  by  lying  down.  Chronic  constipation 
of  a  severe  character  is  almost  alwa\'s  present.  The  bowels 
only  act  as  the  result  of  using  aperients  or  enemata,  and  even 
then  often  not  satisfactorily,  or  intermittently. 

Many  sufferers  from  this  condition  become  markedly  neurotic, 
and  it  is  a  common  cause  of  chronic  invalidism.     As  a  result 


Fig.  33. — Kinking  of  pelvic  colon  from  a  band  of  adhesions. 

of  the  constipation,  they  suffer  from  auto-intoxication,  their 
complexion  is  bad,  they  have  constant  headache  and  neuralgia, 
the  appetite  is  poor,  and  they  lose  weight. 

In  some  cases  there  are  recurring  attacks  of  partial  obstruction, 
with  severe  abdominal  colic,  and  sometimes  vomiting.  i\fter 
the  administration  of  aperients  and  enemata  the  attack 
terminates  with  an  action  of  the  bowels,  but  is  followed  in  the 
course  of  a  few  weeks  by  another. 

Many  of  the  patients  suffer  from  chronic  colitis,  and  pass 
large  quantities  of  mucus  in  the  stools. 

Walking,  or  any  form  of  exercise,  increases  the  pain  and 
discomfort  ;  consequently  the  patient  gets  no  exercise,  and  often 
not  enough  fresh  air  ;    as  a  result  anaemia  often  supervenes. 

The  symptoms  may  persist  for  years,  the  patient  occasionally 


96  ADHESIONS    AND    KINKING 

getting  temporary  relief  as  the  result  of  some  new  treatment, 
only  to  relapse  again  in  the  course  of  a  few  weeks  or  months. 

If  the  adhesions  are  in  the  pelvic  region  there  may  be  pain 
on  micturition.  If  about  the  colon,  they  may  cause  pain  by 
being  dragged  upon  or  stretched,  or  chronic  obstructive 
symptoms  owing  to  their  preventing  free  movement  of  the 
bowel  and  giving  rise  to  sharp  corners  and  angles. 

CHRONIC  OBSTRUCTION  FROM  ANGULATION  OR  KINKING 
OF  THE  COLON. 

From  the  existing  hterature  on  the  subject,  this  condition 
would  not  appear  to  be  very  common,  but  it  is  probably 
more  frequent  than  is  generally  supposed,  and  a  not  uncommon 
cause  of  some  of  the  most  serious  cases  of  constipation. 
It  is  really  the  same  thing  as  chronic  volvulus,  and  cases 
described  as  chronic  volvulus  would  be  more  correctly  placed 
in  this  category. 

In  these  cases  there  is  an  acute  angle,  kink,  or  twist  in  some 
portion  of  the  colon,  usually  in  the  sigmoid  flexure,  which, 
though  it  does  not  entirely  block  the  bowel  lumen,  constricts 
it  to  such  an  extent  as  to  cause  chronic  obstruction  to  the 
passage  of  the  intestinal  contents,  or  causes  the  frequent 
impaction  of  solid  faecal  material  at  this  point,  with  consequent 
recurring  attacks  of  more  or  less  complete  obstruction. 

There  is  good  reason  to  think  that  many  cases  of  so-called 
congenital  dilatation  of  the  colon  are  due  to  kinking  of  the 
bowel  from  an  abnormal  mesentery  ;  but  the  fact  that  the  typical 
enormous  dilatation  and  hypertrophy  of  the  colon  which  is 
here  present  is  not  usually  seen  in  cases  of  kinking,  of  which 
a  considerable  number,  well  authenticated,  have  now  been 
reported,  is  opposed  to  such  a  view. 

It  is  only  comparatively  recently  that  kinking  has  been 
recognized  as  a  cause  of  chronic  obstruction.  Most  of  the 
earliest  cases  were  described  by  Americans — notably  by  Tuttle, 
Delatour,  and  Leroque,  but  similar  cases  had  been  previously 
described  in  England  under  the  title  of  "  chronic  volvulus 
of  the  sigmoid  flexure." 

One  of  the  commonest  situations  for  kinking  to  occur  is  at 
the  junction  of  the  mobile  pelvic  colon  with  the  fixed  upper  end 
of  the  rectum.  The  apex  of  the  pelvic  loop  is  also  a  not 
uncommon  situation. 


OF    THE    COLON 


97 


Tuttle  maintains  that  this  condition  of  acute  angulation  may 
result  from  a  congenital  defect  in  the  formation  of  the  sigmoid 
mesentery,  its  line  of  attachment  being  too  short  and  resulting 
in  excessive  angles  at  the  extremities  of  the  pelvic  loop.  There 
is,  however,  little  or  no  proof  of  this  contention. 

The  condition  may  result  from  an\'  of  the  following  causes  : — 

1.  Contractions  or  adhesions  in  the  mesosigmoid  from 
inflammation. 

2.  Adhesions  between  two  adjacent  portions  of  the  pelvic 
colon  or  between  this  and  some  other  structure. 

3.  Abnormal  length  of  the  mesosigmoid. 

4.  Recurring  volvulus. 

Any  inflammatory  process  which  results  in  the  formation 
of  a  local  cicatrix  or  contraction  in  the  mesosigmoid  may  result 


Fig.  34. — Diagram  to  show  different  ways  in  which  adhesions  may  produce  a  kink  or  obstruc- 
tion. (A)  Two  appendices  epiploicae  adherent  to  one  another.  (B)  The  two  sides  of  a  loop 
adherent  to  one  another.     (C)  A  double  kink  caused  by  a  band  of  adhesions. 


in  the  formation  of  an  acute  kink  or  angle  in  the  pelvic  colon. 
Such  a  condition  may  arise  from  a  caseating  tuberculous  gland 
in  the  base  of  the  mesentery,  from  a  diverticulum,  from  an 
abscess  behind  the  peritoneum,  and  from  such  conditions  as 
perimetritis. 

I  have  operated  in  three  cases  in  which  the  kink  was  found 
to  be  due  to  a  broad  band  of  peritoneal  adhesion  between 
the  pelvic  colon  and  the  left  iUac  fossa.  The  peritoneal  band 
formed  part  of  the  mesentery  on  the  outer  side,  and  was  not 
separated  from  it.  It  was  shorter  than  the  mesentery  itself, 
and  in  consequence  an  acute  and  abnormal  angle  or  flexure 
was  produced  in  the  centre  of  the  pelvic  colon.  In  each  of 
these  cases  the  patient  for  several  years  had  had  difficulty  in 


98  ADHESIONS    AND    KINKING 

getting  the  bowels  to  act  properly.  In  one  case  there  had  for 
some  years  been  frequent  and  severe  attacks  of  pain  and 
obstruction,  and  in  two  others  there  was  a  history  of  severe 
and  intractable  constipation  for  several  years.  In  all,  the 
bowel  trouble  disappeared  after  division  of  the  band.  In  none 
of  them  was  any  definite  cause  found  for  the  formation  of  the 
band. 

One  of  the  commonest  causes  is  undoubtedly  chronic  ulceration 
of  the  pelvic  colon  and  pericolitis,  with  the  consequent  formation 
of  adhesions  between  the  peritoneum  covering  the  base  of  the 
ulcer  and  some  adjacent  structure,  the  subsequent  contraction 
of  the  adhesions  producing  a  kink.  Or  two  contiguous  portions 
of  the  pelvic  colon  may  become  stuck  together,  with  the  result 
that  an  acute  angle  is  formed  at  the  apex  of  the  loop.  In  one 
instance    recorded    by    Tuttle,    two    appendices    epiploicae    on 


Fig.  35. — Double  kink  of  the  pelvic  colon  caused  by  adhesions. 

contiguous  portions  of  the  pelvic  colon  had  become  adherent 
at  their  tips,  thus  forming  a  band  which  tied  the  loop  together 
in  the  centre  and  constricted  it. 

In  quite  a  number  of  the  cases,  appendicitis  has  been  the 
cause.  The  sigmoid  flexure  has  become  adherent  to  the 
appendix  or  caecum  on  the  right  side  of  the  pelvis,  and  the 
weight  of  the  proximal  loop  of  the  pelvic  colon  has  resulted  in 
an  acute  angle  being  formed  at  the  point  of  the  adherence  on 
the  right  side,  while  in  a  few  instances  the  appendix  is  found 
stretching  across  the  pelvis,  adherent  at  its  tip  to  the  sigmoid, 
and  kinking  it. 

The  condition  may  result  from  extensive  pelvic  adhesions 
following  general  or  pelvic  peritonitis.  This  is  well  known, 
and  numerous  instances  have  been  met  with.     In  such  cases 


OF    THE    COLON 


99 


the  pelvic  colon  may  be  bent  into  several  acute  angles  and 
much  contorted,  so  that  it  is  surprising  that  the  faecal  contents 
are  able  to  pass  along  it  at  all. 

In  one  case  {Fig.  35)  two  acute  angles  in  the  pelvic  colon  had 
arisen  from  extensive  adhesions  between  the  sigmoid  and 
the  vertebral  column,  the  result  of  general  peritonitis.  Adhesions 
between  the  ovary  or  tubes  and  the  sigmoid  may  cause  a  kink 
in  a  similar  manner. 

One  would  expect  that  dilatation  and  hypertrophy  of  the 
bowel  above  the  obstruction  would  occur  :  this  is  so,  but  not 
to  any  marked  degree.  In  one  case,  the  bowel  was  ulcerated 
both  above  and  below  the  constricted  point,  but  it  was  doubtful 
if  this  was  true  stercoral  ulceration.     In  several  others,  attacks 


J^ig.  36. — Angulation  of  the  pelvic  colon  caused  by  adhesions  to  the  iliac  fossa.     The  condition 
produced  chronic  obstruction.     (Author's  case). 


of  diarrhoea  would  seem  to  indicate  inflammation  above  the 
stricture.  Fscal  impaction,  and  the  formation  of  stercoral 
calculi  in  the  colon  above  the  constricting  angle,  have  been 
present  in  several  instances.  The  bowels  will  not  act  in  these 
circumstances  without  the  use  of  strong  aperients,  often  aided 
by  enemata  administered  with  a  long  tube. 

The  condition  does  not  appear  to  be  fatal,  except  occasionally 
when  faecal  impaction  has  occurred.  Most  of  what  is  known 
about  it  is  the  result  of  what  has  been  seen  at  operations  done 
with  the  object  of  relieving  the  symptoms  of  chronic  obstruction, 
aided  by  examinations  of  the  bowel  with  the  sigmoidoscope. 
Several  times  it  has  been  possible  to  diagnose  the  condition 


100  ADHESIONS    AND    KINKING 

by  a  sigmoidoscopic  examination,  and  subsequent  operation 
has  confirmed  the  diagnosis.  Normally,  the  pelvic  colon  will 
straighten  out  when  the  sigmoidoscope  is  pasesd,  but  where 
kinking  exists,  an  abnormal  fixed  angle  is  seen  which  cannot 
be  straightened. 

There  have  been  several  instances  in  which  a  patient  has 
been  operated  upon  for  intestinal  obstruction,  and  on  opening 
the  abdomen,  no  obstruction  has  been  discovered.  Several 
cases  have  also  been  recorded  in  which  acute  obstruction  was 
relieved  by  making  an  artificial  anus  above  the  distended  coils 
of  large  bowel,  and,  after  the  obstruction  had  thus  been  relieved,, 
the  bowels  commenced  to  act  by  the  natural  channel.  In  one 
case  the  patient  died  from  an  operation  to  close  the  artificial 
anus,  and  at  the  post-mortem  examination  no  cause  for  the 
obstruction  could  be  found.  In  another,  the  patient  developed 
a  ventral  hernia  in  the  scar  of  the  first  operation,  and  at  the 
second  operation,  which  was  undertaken  to  remedy  this,  a 
careful  exploration  of  the  colon  was  made  to  find  the  cause 
of  the  previous  obstruction,  but  nothing  was  discovered. 

These  are  probably  cases  of  acute  angulation  of  the  colon 
causing  partial  obstruction  to  the  bowel  lumen — in  all  of  them 
there  was  a  history  of  repeated  attacks  of  partial  obstruction 
and  abdominal  pain — the  acute  obstruction  resulting  from  the 
colon  becoming  distended  with  fseces  and  gas.  Distention 
would  further  accentuate  the  angulation  or  kink,  and  prevent 
anything  from  passing  along  the  lumen.  When  the  distention 
was  relieved  by  colotomy,  the  kink  was  able  to  untwist,  and  the 
lumen  again  became  patent.  A  careful  examination  of  the 
mesosigmoid  in  similar  cases  will  probably  reveal  that  it  is. 
unduly  long,  or  otherwise  deformed. 

The  following  case  well  illustrates  this  condition  of  kinking, 
of  the  pelvic  colon  :- — 

Case. — Mr.  I ,  a  gentleman  aged  25,   was  brought  to  me  by 

Dr.  Leonard  Williams  on  account  of  severe  chronic  constipation. 
He  had  suffered  from  this  condition  for  three  or  four  years.  Every 
kind  of  non-operative  treatment  had  been  carefully  tried,  but  he 
was  no  better  and  was  anxious  to  have  something  further  done. 
A  sigmoidoscopic  examination  revealed  a  kink  in  the  pelvic  colon 
and  fixation  to  the  left  iliac  fossa. 

On  opening  his  abdomen  a  band  of  adhesions  was  found  binding 
down  the  middle  of  the  pelvic  colon  to  the  left  iliac  fossa  and  causing 
a  sharp  bend  [see  Fig.  36).     The  bowel  was  freed,  and  the  peritoneum 


OF    THE    COLON  loi 

carefully  closed  in  so  as  to  leave  no  raw  surface.  He  made  a  good 
recovery,  and  the  bowels  began  to  act  regularly  and  without 
abdominal  pain  at  once.  When  heard  from  six  months  later  his 
bowels  were  acting  regularly  without  aperients. 

Favel  reports  a  case  in  which  a  long  mesentery  to  the  caecum 
and  ascending  colon  was  associated  with  severe  pain  in  the 
abdomen.  The  patient  was  a  woman,  aged  32,  who  had 
suffered  from  several  severe  attacks  of  pain  thought  to  be  due 
to  appendicitis.  The  appendix  was  removed  and  found,  on 
microscopic  examination,  to  be  ulcerated,  but  there  was  no 
relief  from  the  pain.  A  second  operation  revealed  the  fact  that 
there  was  a  long  mesentery  to  the  caecum  and  ascending  colon, 
with  a  band  of  adhesions  fixing  the  ascending  colon  to  the 
abdominal  wall.  The  whole  caecal  angle  tended  to  revolve 
around  this  band  and  become  twisted.  The  band  was  divided 
and  the  outer  wall  of  the  caecum  anchored  by  sutures  to  the 
iliac  fossa.     This  cured  the  patient. 

Paul  Lercque  records  a  case  in  which  colitis  and  severe 
constipation  were  caused  by  shortening  of  the  mesosigmoid 
by  adhesions.  Division  of  the  adhesions  resulted  in  a  cure 
of  the  condition. 

I  have  been  able  to  collect  twenty-four  cases  of  angulation 
or  kinking  of  the  colon  causing  severe  chronic  constipation  or 
complete  obstruction,  and  in  which  the  condition  was  verified  by 
operation  or  post  mortem.  There  can  be  little  doubt  that 
many  bad  cases  of  chronic  constipation  which  are  not  infre- 
quently met  with  are  due  to  this  cause. 

Unless  angulation  is  suspected  and  carefully  sought  for,  it 
may  easily  be  overlooked,  even  at  an  operation,  when  the 
abdomen  is  explored.  The  kink  often  occurs  only  when  the 
patient  is  standing,  and  the  force  of  gravity  can  pull  down  the 
pelvic  colon  into  the  pelvis.  When  the  patient  is  recumbent, 
as  he  naturally  will  be  during  the  operation,  no  kink  may  be 
seen.  The  condition,  however,  wdll  not  easily  be  missed  if  the 
pelvic  colon  is  carefully  examined  for  the  presence  of  adhesions, 
the  length  of  its  mesentery,  and  the  facility  with  which  it  can 
be  kinked  at  its  fixed  ends. 

Obstruction  may  result  from  a  portion  of  the  omentum  being 
caught  in  a  hernial  sac,  or  in  an  operation  scar,  in  such  a  way 
as  to  kink  the  transverse  colon  and  obstruct  the  lumen.  I  once 
saw  a  case  where  a  patient  died  from  acute  obstruction  due 


102  ADHESIONS    AND    KINKING 

to  this  cause  :  he  was  suffering  from  cancer  of  the  rectum,  and 
a  left  inguinal  colotomy  had  been  performed.  The  colotomy 
opening  did  not  act,  and  five  days  after  the  operation  the  patient 
had  developed  all  the  sj'mptoms  of  intestinal  obstruction.  On 
opening  the  abdomen,  it  was  discovered  that  a  piece  of  the  great 
omentum  had  been  taken  up  in  the  spur  stitch  in  performing 
the  colotomy  ;  this  had  caused  an  acute  angle  in  the  centre 
of  the  transverse  colon,  which  had  completely  blocked  the 
lumen.  Clark  has  recorded  a  similar  case,  in  which  acute 
obstruction  resulted  from  the  omentum  becoming  adherent  in  a 
left  inguinal  hernia.  The  patient  was  successfully  operated  upon. 
Adhesions  between  the  gall-bladder  and  the  hepatic  flexure 
of  the  colon  may  cause  obstruction.  A  case  is  recorded  by 
Voelcker,  in  which  the  fundus  of  the  gall-bladder  had  ulcerated 
into  the  colon. 

Treatment. 

Non-Operative  Treatment. — While  much  can  be  done 
by  non-operative  methods  to  prevent  the  formation  of  adhesions 
after  operations  or  an  attack  of  peritonitis,  they  often  fail  when 
the  condition  has  once  become  well  established.  When 
abdominal  pain  and  discomfort  are  the  chief  symptoms 
complained  of,  a  thorough  trial  should  be  given  to  non-operative 
methods  before  proceeding  to  perform  laparotomy.  In  those 
cases  where  there  are  recurring  attacks  of  obstruction,  palliative 
measures  seldom  do  any  good,  and  operation  is  often  the  only 
method  of  relieving  the  symptoms. 

It  is  usually  impossible  to  tell  how  much  benefit  will  result 
from  careful  medical  treatment,  and  it  is  therefore  always 
advisable,  unless  serious  symptoms  are  threatening,  to  try 
the  effect  of  massage  and  exercises,  before  proceeding  to  per- 
form laparotomy. 

Much  can  often  be  done  by  properly  applied  massage.  For 
this  to  be  effective,  however,  it  must  be  well  done,  and  combined 
with  other  forms  of  treatment.  Too  often  the  patient  is  told  that 
he  is  to  have  massage,  and  is  allowed  to  continue  his  usual  mode 
of  life,  and  the  masseur  simply  comes  in  for  half  an  hour  a  few 
times  a  week.  In  these  days  also,  when  almost  every  nurse 
considers  herself  a  skilled  masseuse,  sufficient  care  is  not  taken 
to  see  that  really  skilled  massage  is  being  given.  Such  treatment 
is  generally  useless.     The  patients  should  for  preference  be  in 


OF    THE     COLON  103 

some  nursing-home  or  institution  where  they  can  be  kept  under 
observation,  and  where  proper  electrical  and  vibratory  apparatus 
is  at  hand.  A  really  skilled  masseuse  is  essential,  and  abdominal 
massage  should  be  commenced  gently.  At  first  the  patient 
should  be  massaged  for  not  more  than  ten  minutes,  twice  a  day. 
This  is  much  better  than  for  twenty  minutes  once  a  day,  and 
it  will  not  cause  so  much  fatigue. 

When  possible,  the  massage  should  be  combined  with  electrical 
treatment.  The  sinusoidal  current  applied  to  the  abdomen 
appears  to  be  the  most  useful.  The  instrument  should  be  capable 
of  giving  a  quick  break,  and  the  current  should  be  applied  for 
about  ten  minutes  at  a  time.  High-frequency  currents  also 
seem  to  do  good  in  some  cases,  but  it  is  essential  that  the 
apparatus  should  be  a  good  one,  and  not  one  of  the  toys  so 
often  seen  in  so-called  electrical  institutes. 

The  electrical  application  should  be  given  first,  and  should 
be  followed  by  massage.  As  the  patient  grows  accustomed  to 
the  treatment,  the  period  may  be  extended,  but  fifteen  minutes' 
massage  is  usually  sufficient,  except  in  patients  with  very  rigid 
abdominal  walls.  After  the  first  week,  exercises  against 
resistance  should  follow  the  massage.  These  exercises  should 
be  those  which  contract  the  abdominal  muscle  and  which  flex 
the  spine  and  thigh.  Such  exercises  do  good  by  moving  the 
parietal  peritoneum  through  the  agency  of  the  muscles  in 
contact  with  it. 

Treatment  should  be  continuous  at  first,  and  the  shortest 
time  for  a  course  which  will  do  any  real  good  is  from  a  month 
to  six  weeks.  During  this  period  the  patient  should  not  be 
kept  in  bed,  except,  perhaps,  during  the  first  few  days,  but 
should  be  got  out  daily  for  a  short  time.  After  a  course  of 
treatment  the  patient  should  be  instructed  to  take  regular 
exercise,  and  to  keep  the  bowels  acting  daily.  The  best  forms 
of  exercise  are  probably  walking  and  riding.  If  marked 
improvement  follows,  the  patient  should  have  a  second  and 
shorter  course  of  massage  and  electricity  in  about  two  months' 
time. 

Injections  of  fibrolysin,  a  drug  which  is  said  to  cause  softening 
of  adhesions,  have  also  been  used  in  these  cases,  and  good  results 
are  claimed.  The  treatment  is  too  new  to  warrant  any  opinion 
as  to  its  benefit,  but  as  the  injections  do  not  seem  to  cause 
any  unpleasant  results,  the  drug  may  be  tried   in  conjunction 


104  ADHESIONS    AND    KINKING 

with  massage.  The  injections  should  be  given  intramuscularly, 
preferably  into  the  buttocks,  every  two  or  three  days. 

In  many  cases,  although  some  improvement  follows  a  thorough 
course  of  massage,  the  patient  soon  relapses  to  the  old  condition, 
and  in  the  worst  cases  little,  if  any,  improvement  occurs. 
Where  a  definite  obstruction  from  kinking  has  occurred,  nothing 
short  of  operation  will  do  any  good.  Operation  is  indicated 
when  there  is  serious  difficulty  in  getting  the  bowels  to  act, 
and  also  when  the  patient  is  so  greatly  incapacitated  by  his 
symptoms  as  to  prevent  his  attending  to  the  ordinary  affairs 
of  hfe. 

Operative  Treatment. — The  operation  consists  in  separating 
or  dividing  adhesions  and  re-establishing  the  normal  course 
of  the  bowel.  Where  only  a  few  adhesions  or  a  single  band 
are  present  this  may  be  an  easy  matter,  but  in  other  cases  it 
may  prove  most  difficult,  either  on  account  of  the  density  and 
closeness  of  the  adhesions,  or  because  the  bowel  wall  is  friable 
from  secondary  ulceration.  In  one  instance,  at  least,  the  bowel 
was  ruptured  in  attempting  to  straighten  it. 

When  the  adhesions  are  very  firm,  or  serious  difficulty  is 
experienced  in  straightening  the  bowel,  the  best  procedure  is 
probably  to  resect  the  involved  loop  and  unite  the  ends  of  the 
bowel  if  this  can  be  done,  or  to  short-circuit  the  obstructing 
angle  by  lateral  anastomosis. 

It  is  not,  however,  sufficient  merely  to  divide  the  adhesions 
in  any  case,  since,  if  raw  surfaces  uncovered  by  peritoneum  are 
left,  the  adhesions  are  almost  certain  to  re-form  and  re-establish 
the  original  condition.  The  prevention  of  subsequent  adhesions 
constitutes  the  chief  difficulty  in  these  cases.  Various  methods 
have  been  advocated  by  different  surgeons,  and  various 
substances  have  been  used  to  cover  the  raw  surfaces  with 
the  object  of  preventing  the  formation  of  adhesions.  Thus, 
painting  over  with  gum  or  glucose  has  been  tried.  Covering 
them  with  gold  leaf  has  been  done  a  good  deal,  and  with 
apparently  good  results.  Filling  the  abdomen  with  salt  solution, 
and  subsequently  giving  large  rectal  or  subcutaneous  injections 
of  water  or  salt  solution,  have  been  depended  upon  by  some 
surgeons,  while  others  again  believe  in  abdominal  massage  and 
electricity  applied  to  the  abdomen  for  some  time  after  operation. 

None  of  these  methods  have  been  entirely  successful  in 
preventing  the  re-formation  of  adhesions,  and  there  are  numerous 


OF    THE    COLON  105 

instances   in  which  adhesions  have    re-formed    after    repeated 
operations. 

Undoubtedly  the  best  method  is  to  bring  the  peritoneum 
carefuUy  together,  so  as  to  cover  ah  the  raw  surfaces  left  by 
division  of  the  adhesions.  This  involves  some  form  of  plastic 
operation,  and  considerable  care  and  patience.  It  is  often 
possible,  after  dividing  a  peritoneal  band  transversely,  to  stitch 
the  resulting  wound  in  the  peritoneum  in  a  longitudinal 
direction,  so  as  completeh'  to  cover  in  the  raw  surface,  and  at 
the  same  time  straighten  the  bowel.  The  following  is  a  good 
instance  of  the  type  of  case  which  can  onty  be  treated  satisfac- 
torily by  operation. 

Case. — The  patient,  a  married  lady,  was  recently  sent  to  me  by 
lier  doctor.  For  ten  years  she  had  been  a  chronic  invalid  with 
raucous  colitis.  She  suffered  from  a  chronic  pain  in  the  abdomen, 
which  at  times  became  severe,  and  was  always  worst  on  the  left 
side.  She  had  lost  weight,  and  always  felt  ill  and  depressed.  She 
had  fits  of  weeping  and  misery  on  the  shghtest,  and  often  upon  no, 
provocation,  and  was  unable  to  go  about  or  enjoy  life  in  the  ordinary 
way.  She  had  an  earthy  complexion,  and  her  appearance  when 
I  saw  her  was  typical  of  toxaemia  or  auto-intoxication.  Her  stools 
contained  large  quantities  of  mucus,  and  often  consisted  of  little 
else.  A  curious  and  unusual  symptom  was  that  the  presence  of 
anything  in  the  rectum  caused  an  uncontrollable  desire  to  go  to 
stool,  and  much  tenesmus.  She  had  been  under  medical  treatment 
for  years,  and  all  the  recognized  non-operative  measures  had  been 
tried.  On  examining  the  bowel  with  the  sigmoidoscope,  I  found 
the  mucosa  quite  normal  in  appearance.  In  the  middle  of  the 
sigmoid,  however,  the  bowel  was  firmly  fixed  and  angulated, 
apparently  by  adhesions.  The  uterus  was  also  found  to  be  markedly 
retroflexed.  It  seemed  probable  that  the  tenesmus  from  which  she 
suffered  was  due  to  the  condition  of  the  uterus,  and  a  gynaecologist 
who  saw  her  with  me  confirmed  this  view.  I  opened  the  abdomen 
and  found  a  number  of  firm  adhesions  binding  down  and  kinking 
the  middle  of  the  sigmoid  flexure  ;  these  were  divided,  and  the 
wound  left  in  the  peritoneum  sewn  up.  The  uterus  was  also  drawn 
forward  and  anchored  to  the  abdominal  Avall,  so  as  to  correct  the 
position.  The  patient  made  a  good  recovery,  and  all  her  symptoms 
have  now  completely  disappeared.  When  I  last  saw  her,  some 
months  after  the  operation,  she  had  put  on  weight,  her  complexion 
was  good,  she  no  longer  had  any  mucus  in  the  stools,  and  she  told 
jue  she  never  remembered  feeling  so  well  and  fit. 

By  similar  means,  and  by  utilizing  loose  folds  of  peritoneum, 


io6  KINKING    OF    THE    COLON 

appendices  epiploicae,  or  omentum  to  cover  in  defects  in  the 
peritoneum,  much  may  be  done  to  prevent  the  recurrence  of 
adhesions.  Absolute  ascepticity,  and  great  care  in  removing 
all  blood-clot  from  the  peritoneal  cavity,  are,  however,  the  most 
important  factors  in  preventing  their  formation  ;  and  a 
subsequent  course  of  massage  and  electricity  is  advisable. 

The  actual  details  of  operation  must  vary  with  every  case. 

Many  of  the  operations  which  aim  at  relieving  obstructive 
angulation  of  the  colon  or  chronic  volvulus,  by  fixation  of  the 
bowel  with  sutures,  fail  to  cure  the  condition.  The  patient 
is  usually  much  improved,  or  apparently  cured,  immediately 
after  the  operation  ;  but  some  months  later  the  old  condition 
comes  back,  and  the  constipation  and  chronic  obstruction  are 
soon  as  bad  as  ever.  If  a  subsequent  operation  is  performed, 
it  is  found  that  the  adhesions  have  all  given  way  and  allowed 
the  bowel  to  resume  its  previously  abnormal  position. 

This  seems  to  occur  no  matter  what  method  of  fixation  is 
adopted,  or  how  carefully  it  is  performed,  and  it  therefore 
seems  as  if  the  best  operation  in  such  cases  would  be  to  resect 
the  affected  loop  of  colon,  or  at  least  some  part  of  it.  This  will 
effectually  prevent  recurrence  by  making  the  sigmoid  a  straight 
tube.  This  operation  was  adopted  by  Mr.  Moynihan  with 
success  in  one  case  after  fixation  had  failed. 

REFERENCES. 

Baisch. — Beitrage  zur  Gebeits.  1905,  p.  435. 
Delatour. — Annals  of  Surg.  Nov.  1905. 
TuTTLE. — N.Y.  Med.  Journ.  March,  1908. 
Leroque. — Annals  of  Surg.  Nov.  1906. 


107 


Chapter  IX. 

ENTEROPTOSIS   OF   THE   TRANSVERSE   COLON  AND 
HERNIA     OF     THE     COLON. 

ENTEROPTOSIS  OF  THE  TRANSVERSE  COLON. 

Enteroptosis  is  undoubtedly  an  important  causal  factor  in 
many  cases  of  bad  chronic  constipation  and  in  chronic  mucous 
colitis.  It  is  necessary  to  distinguish  between  true  cases  of 
visceroptosis  due  to  the  abdominal  organs  falling  towards  the 
pelvis,  and  those  in  which  the  apex  of  the  transverse  colon  is 
dragged  down  and  fixed  in  the  pelvis  by  adhesions  resulting 
either  from  a  previous  peritonitis  or,  less  frequently,  from 
adhesions  to  the  neck  of  an  old  hernia.  These  latter  cases  are 
often  incorrectly  described  as  enteroptosis. 

In  extreme  visceroptosis  the  centre  of  the  transverse  colon 
may  lie  behind  the  bladder,  and  I  have  seen  two  cases  in  which 
it  lay  in  Douglas'  pouch,  and  the  lower  border  of  the  stomach 
lay  behind  the  symphysis  pubis.  It  is  not  uncommon  to  find 
the  centre  of  the  transverse  colon  as  low  as  the  brim  of  the 
pelvis.  The  transverse  colon  becomes  longer  from  stretching, 
and  often  somewhat  dilated.  The  splenic  and  hepatic  angles 
are  to  some  extent  dragged  down  with  the  transverse  colon, 
and  thus  come  to  occupy  a  lower  position,  while  the  angle 
formed  at  the  two  flexures  is  considerably  more  acute  than  in 
the  normal  condition.  The  normal  position  of  the  centre  of 
the  transverse  colon  is  at  about  the  level  of  the  umbilicus 
or  a  little  below  this  ;  but  in  complete  enteroptosis  the  centre 
of  the  transverse  colon  becomes  a  pelvic  organ. 

Prolapse  of  the  transverse  colon  cannot  occur  without  gastro- 
ptosis,  the  relative  positions  of  these  two  portions  of  the  alimen- 
tary tract  remaining  much  as  before.  In  fact,  enteroptosis 
of  the  colon  only  occurs  as  part  of  a  general  visceroptosis  in 
which  the  colon,  stomach,  spleen,  liver,  and  often  the  kidneys, 
are  all  involved.     The  diaphragm  descends,  and  the  peritoneal 


io8 


ENTEROPTOSIS    OF    THE 


connections  normally  supporting  these  structures  stretch  and 
elongate. 

Much  importance  has  been  attached  to  the  increased  angles 
or  kinks  at  the  hepatic  and  splenic  angles  of  the  colon  which 
are  produced  in  visceroptosis,  especially  with  regard  to  their 
causing  obstruction  and  chronic  constipation.  It  seems 
doubtful,  however,  whether  any  serious  obstruction  to  the 
bowel  lumen  is  thus  produced.  If  it  were  so,  one  would  expect 
to  meet  with  cases  of  acute  obstruction  from  this  cause,  but 
I  have  been  quite  unable  to  find  any  unless  complicated  by 
adhesions.     Dr.  Hertz,  who  has  studied  visceroptosis  under  the 


Fig. 


-Diagram  showing  the  position  occupied  by  the  stomach,  and  transverse  colon  in  a  bad 
case  of  visceroptosis. 


X  rays,  has  not  seen  any  delay  in  the  passage  of  the  fasces  past 
the  flexures,  such  as  might  be  expected  to  occur  if  there  was 
obstruction  of  the  lumen. 

The  chronic  obstruction,  or  rather  constipation,  which 
undoubtedly  does  occur  in  cases  of  visceroptosis,  is  doubtless 
chiefly  due  to  the  sagging  of  the  central  portion  of  the  transverse 
colon,  which  tends  to  the  accumulation  of  faeces  at  this  part, 
and  to  the  fact  that  atony  and  weakness  of  the  bowel  muscula- 
ture is  generally  an  associated  condition. 

After  visceroptosis  has  existed  for  some  time,  secondary  changes 


TRANSVERSE    COLON  109 

occur  in  the  transverse  colon.  The  normal  pouches  or  saccula- 
tions between  the  longtitudinal  muscle-bands  become  larger, 
the  whole  bowel  is  stretched  and  more  capacious,  and  the  muscle 
coats  atrophy.  Chronic  inflammatory  changes  in  the  mucous 
membrane,  giving  rise  to  the  symptoms  of  mucous  colitis,  are 
common  in  such  cases. 

It  seems  certain  that  one  of  the  most  important  factors — if 
not  the  most  important — in  visceroptosis  is  weakness  of  the 
abdominal  muscles.  The  abdominal  organs  are  kept  in  position 
chiefly  by  the  positive  pressure  always  present  in  the  abdominal 
cavity  from  tonic  contraction  of  the  abdominal  wall. 

In  visceroptosis  the  abdominal  walls  are  usually  weak  and  the 
muscles  have  wasted.  Many  of  the  secondary  results  of  this 
condition  must  certainly  be  attributed  to  the  venous  stagnation 
in  the  abdominal  vessels  which  occurs  as  the  result  of  lowered 
intra-abdominal  pressure. 

Diagnosis. 

Prolapse  of  the  transverse  colon  can  usually  be  diagnosed 
with  certainty  by  means  of  the  X  rays,  and  the  position  of 
the  stomach,  which  can  be  ascertained  by  palpation,  is  also 
a  useful  guide  as  to  that  of  the  transverse  colon.  Thus, 
if  we  find  on  palpation  that  the  lower  edge  of  the  stomach 
comes  down  almost  to  the  brim  of  the  pelvis,  we  may  assume 
that  the  centre  of  the  transverse  colon  lies  in  the  pelvis. 

Treatment. 

The  patient  often  obtains  much  relief  from  wearing  a 
properly  fitting  belt.  This  should  come  well  down  to  the 
pelvic  brim,  and  should  support  the  abdominal  wall  in  a 
direction  towards  the  dorsal  spine.  If  properly  fitted,  such  a 
belt  will,  by  restoring  the  intra-abdominal  pressure,  do  much  to 
relieve  the  worst  symptoms.  The  object  of  the  belt  is  not 
to  act  as  a  direct  support  to  the  stomach  and  colon,  though  this 
is  often  stated  to  be  the  case,  but  as  an  artificial  abdominal 
wall,  and  thus  to  restore  the  intra-abdominal  pressure  which  has 
been  lowered  by  lax  and  badly-acting  abdominal  muscles. 

In  a  normal  individual  the  various  abdominal  organs  are 
protected  from  the  effects  of  gravity — which  would  otherwise 
tend  to  displace  them  all  towards  the  pelvis — by  the  intra- 
abdominal pressure  rather  than  by  other  factors. 


no  ENTEROPTOSIS     OF    THE 

Normally,  the  intra-abdominal  pressure  is  sufficient  to 
counteract  the  effects  of  gravity  in  the  standing  position,  and 
the  pressures  on  any  intra-abdominal  organ  are  practically 
equal  in  all  directions,  so  that  the  slight  anchoring  supports 
which  are  provided  by  the  various  peritoneal  connections  are 
sufficient  to  retain  the  various  organs  in  their  correct  relative 
positions.  When,  however,  the  abdominal  walls  become  lax 
from  any  cause,  the  intra-abdominal  pressure  is  lowered,  and 
in  some  cases  almost  becomes  negative,  with  the  result  that 
the  organs  in  the  upper  part  of  the  abdominal  cavity  are 
supported  only  by  their  peritoneal  connections,  which  being 
quite  inadequate  soon  yield,  allowing  the  organs  to  prolapse. 
By  means  of  a  properly  made  belt,  which  should  be  worn  always, 
except  at  night,  the  intra-abdominal  pressure  can  be  restored 
and  the  prolapsed  organs  will  again  be  able  to  function  properly. 
Much  can  also  be  done  in  some  cases  to  develop  the  abdominal 
muscles  by  suitable  exercises. 

Many  operations  have  been  done  with  the  object  of  relieving 
the  chronic  obstruction  to  the  passage  of  the  faecal  contents 
along  the  bowel  which  results  from  prolapse  of  the  transverse 
colon.  Very  careful  consideration  is,  however,  necessary  before 
deciding  upon  such  operations.  It  is  obviously  impossible  to 
replace  the  transverse  colon  in  its  normal  position,  and  secure 
it,  without  also  fixing  the  stomach,  and  any  operation  which 
will  entail  a  large  abdominal  incision  or  cutting  the  muscles 
transversely  will  tend  rather  to  increase  than  diminish  the 
tendency  to  visceroptosis,  by  weakening  the  abdominal  wall. 

The  operations  which  have  been  performed  are  as  follows  : — 

1.  Suspension  of  the  transverse  colon  by  suturing  the  omentum 
to  the  abdominal  wall  high  up. 

2.  Shortening  of  the  gastric  ligaments. 

3.  Repair  of  the  abdominal  wall  (if  damaged  as  the  result 
of  child-birth,  etc.). 

4.  Excision  of  the  whole  colon. 

Operations  which  aim  at  suspension  of  the  prolapsed  bowel 
are  unsound  in  theory  and  almost  invariably  fail.  It  is  hardly 
to  be  expected,  when  the  normal  suspensory  ligaments  have 
failed  to  support  the  bowel  against  a  lowered  intra-abdominal 
tension,  that  artificial  ones  will  do  so.  Repair  of  the  abdominal 
wall,  in  cases  where  the  recti  have  become  separated,  is  a 
sound  operation,  and  will  do  good  in  suitable  cases. 


TRANSVERSE     COLON  m 

Surgical  operations  have  often  been  performed  for  this 
condition,  but  they  afford  no  certainty  of  reUef,  and  by  damaging 
the  abdominal  wall  may  make  matters  worse.  They  should 
not  be  done  unless  medical  treatment  has  been  well  tried  and 
has  quite  failed  to  ameliorate  the  symptoms,  and  unless  their 
severity  justifies  an  often  dangerous  operation,  the  result  of 
which  is  more  than  doubtful. 

HERNIA     OF     THE     COLON. 

Hernia  of  the  colon  is  an  uncommon  condition,  as  from  its 
position  at  the  back  of  the  abdomen  the  colon  is  prevented 
from  reaching  the  hernial  orifices,  even  should  its  mobility  be 
sufficient. 

Out  of  forty-seven  cases  of  irreducible  hernia  collected  from 
the  records  of  St.  Thomas's  Hospital  by  Mr.  Corner,  the  colon 
was  found  in  the  sac  in  only  one. 

But  although  this  is  one  of  the  rare  forms  of  hernia,  it  is  of 
considerable  interest,  owing  to  the  often  unusual  relationship 
between  the  bowel  and  its  sac.  The  parts  of  the  colon  which 
may  get  into  a  hernial  sac  are  those  which  possess  a  mesentery, 
either  normally  or  as  the  result  of  some  congenital  abnormality 
of  the  peritoneum.  Thus  the  caecum,  transverse  colon,  and 
pelvic  colon  ma}^  be  found  in  hernial  protrusions. 

The  caecum,  if  it  possesses  a  meso-csecum,  may  find  its  way 
into  one  of  the  hernial  openings.  It  is  not  uncommon  in 
infants  and  young  children  to  find  the  caecum  and  appendix 
in  a  right  inguinal  hernia.  This  can  also  occur  in  the  adult 
if  the  caecum  has  a  mesentery. 

The  caecum  may  similarly  find  its  way  into  a  femoral  hernia, 
and  very  rarely  may  be  found  in  a  left  inguinal  hernia.  For 
the  cfficum  to  be  able  to  get  into  the  latter,  however,  it  must 
possess  a  very  long  mesentery,  or  a  common  mesentery  with 
the  small  bowel. 

Mr.  Russel  Rendle  recently  recorded  a  case  in  which  the 
caecum  was  found  in  a  strangulated  left  inguinal  hernia.*  The 
patient  was  a  male  infant  nine  months  old,  who  was  admitted 
to  the  South  Devon  Hospital  with  a  strangulated  left  inguinal 
hernia.  At  the  operation,  on  opening  the  sac  of  the  hernia, 
it  was  found  to  contain  a  loop  of  small  bowel,  and  the  caecum 

*  Lancet,   1908,  i.  p.   1076. 


112 


HERNIA    OF 


and  appendix.  The  hernia  was  reduced  and  a  radical  cure 
performed.     The  child  recovered. 

A  case  in  which  a  left  femoral  hernia  contained  the  caecum 
is  recorded  in  St.  Bartholomew's  Hospital  Reports,  vol.   xxvii. 

In  caecal  hernia  there  is,  as  a  rule,  a  complete  sac,  but  occasion- 
ally, when  the  caecum  is  found  in  a  right  inguinal  hernia,  it 
comes  down  behind  the  peritoneum  and  forms  part  of  the 
wall  of  the  sac. 

The  pelvic  colon  is  also  sometimes  found  in  a  hernial  sac. 
If  it  has  an  abnormally  long  mesentery,  it  may  become  herniated 
in  the  same  way  as  the  small  bowel.  In  this  case  there  will  be 
a  complete  sac.  It  may  also  be  brought  down  into  the  wall  of 
a  large  left  inguinal  hernia  by  the  peritoneum  being  dragged 


J^zg.  38. — Diagram  showing  different  forms  of  hernia  of  the  colon  : — (A)  the  colon  forming  part 
of  the  sac  wall.  (B)  the  colon  completely  inside  the  sac.  (C)  the  colon  partly  inside  the  sac. 
(D)  showing  the  manner  in  which  the  small  intestine  in  a  large  left  scrotal  hernia  may,  by 
dragging  on  the  parietal  peritoneum,  pull  down  the  pelvic  colon  into  the  wall  of  the  sac.  The 
peritoneum  is  shown  in  red. 

down  to  form  the  sac  wall.  This  will  only  occur  in  the  case 
of  a  large  scrotal  hernia,  and  the  colon,  under  these  circumstances, 
will  be  behind  the  peritoneum  and  will  form  part  of  the  sac 
wall. 

It  may  also  occur  as  a  congenital  hernia  owing  to  the 
peritoneum  being  dragged  down  to  an  abnormal  extent  in  the 
descent  of  the  left  testicle.  In  this  case  the  sac  will  either  be 
absent  or  incomplete.  A  congenital  hernia  of  the  colon  with 
a  complete  sac  may  occur,  however,  owing  to  the  mesosigmoid 
being  congenitally  too  long. 

The  transverse  colon  is  not  uncommonly  found  in  a  large 
umbilical  or  ventral  hernia.  It  seldom  gets  strangulated, 
however,  in  such  circumstances,  though  the  writer  has  heard  of 


THE    COLON  113 

two  cases  in  which  strangulation  of  the  transverse  colon  occurred 
as  the  result  of  adhesions  to  the  neck  of  an  umbilical  hernia. 
The  transverse  colon  may  also  get  into  the  sac  of  an  inguinal 
or  femoral  hernia,  and  Mr.  Paterson  has  recorded  two  cases 
of  this  condition.*  In  one,  the  transverse  colon  was  found 
in  a  femoral,  and  the  other  in  an  inguinal  hernia,  both  on  the 
left  side.  Strangulation  occurred  in  both  cases.  In  order  for 
this  to  be  possible,  the  transverse  colon  must  reach  much 
lower  than  normal.  The  omentum  gets  into  the  hernia  first 
and  drags  the  colon  after  it. 

In  all  cases  of  hernia  of  the  colon,  with  the  exception  of  caecal 
hernia,  strangulation  is  readily  produced  owing  to  the  solid 
nature  of  the  contents.  Rarely  the  ascending  or  descending 
colon  ma}^  be  found  in  the  sac  of  a  lumbar  hernia. 

The  chief  importance  of  hernia  of  the  colon  is,  that  in  those 
cases  where  the  colon  passes  down  outside  the  peritoneum  and 
lies  in  the  wall  of  the  sac,  great  difficulty  may  be  experienced 
in  operating  upon  the  hernia.  Unless  the  condition  is  recognized, 
which  is  not  easy,  the  bowel  may  be  cut  into,  and  in  any  case 
it  may  be  difficult  to  return  it  into  the  abdomen. 

The  diagnosis  of  hernia  of  the  colon  as  opposed  to  hernia 
of  the  small  intestine  is  not  possible  apart  from  operation. 

Treatment. 

The  treatment  of  a  hernia  containing  the  colon  does  not 
differ  from  that  of  an  ordinary  hernia  containing  small  bowel, 
except  when  the  colon  forms  part  of  the  sac  wall.  There  is  a 
danger  in  such  cases  of  cutting  into  the  colon,  or  of  including 
a  portion  of  its  wall  in  the  ligature  when  tying  off  the  sac. 

If  the  surgeon  is  aware  of  the  possibility  of  a  hernia  of  the 
colon  being  present,  he  will  usually  be  able  to  detect  the  condition 
when  the  sac  is  opened.  Any  adhesions  should  be  most  carefully 
divided,  and  the  posterior  part  of  the  sac  should  not  be  separated, 
but  returned,  together  with  the  bowel,  into  the  abdominal 
cavity.  In  doing  this,  great  care  must  be  taken  not  to  damage 
the  blood-supply  of  the  bowel.  The  deficiency  in  the  peritoneum 
should  be  closed  with  stitches  as  carefully  as  possible. 

*  Lancet,   1908,  vii.  p.  237. 


114 


Chapter    X. 

INT  USS  USCEPTION. 

Intussusception  is  a  condition  in  which  one  portion  of  the 
bowel,  usually  the  upper,  is  invaginated  into  an  adjacent 
portion.  It  may  occur  in  any  part  of  the  alimentary  canal,  but 
in  the  majority  of  cases  the  lower  portion  of  the  ileum  is 
invaginated  into  the  colon  (ileo-colic  intussusception).  The 
invagination  may,  however,  be  entirely  confined  to  the  colon 
(colic  intussusception).  It  may  involve  a  short  portion  of  the 
colon  or  its  entire  length,  so  that  the  ileo-cgecal  valve  protrudes 
at  the  anus.  There  are  many  varieties  of  intussusception, 
depending  upon  the  part  of  the  bowel  involved,  the  starting- 
point  of  invagination,  and  the  number  of  layers  entering  and 
leaving  the  invaginated  portion  of  bowel. 

An  intussusception  may  start  in  any  portion  of  the  colon,  but 
it  is  always  the  upper  portion  which  is  invaginated  into  the  lower. 
Retrograde  intussusceptions  do  occur,  but  only  during  death  or 
as  the  result  of  asphyxia  ;   they  are  not  met  with  in  practice. 

More  than  one  intussusception  may  be  present  in  the  same 
patient,  but  such  conditions  are  rare.  Cases  of  intussusception 
involving  the  colon  are  usually  divided  into  :  (i)  ileo-caecal, 
(2)  ileo-colic,  (3)  caecal,  (4)  colic,  and  (5)  appendicular.  The 
subdivisions  are  not  of  much  practical  importance,  as  they  merely 
depend  upon  the  portion  of  bowel  which  originates  the  in- 
vagination, and  the  results  of  the  condition  are  the  same  in  all. 

The  commonest  variety  is  the  ileo-caecal,  in  which  the  ileo- 
caecal  valve  forms  the  apex  of  the  invagination. 

In  some  cases  the  intussusception  becomes  itself  invaginated 
into  the  colon  below  it,  thus  producing  a  double  intussusception. 
This  condition  may  even  be  repeated,  resulting  in  triple  and 
quadruple  intussusceptions. 

As  a  rule  the  intussusception  increases  in  length  at  the  expense 
of  the  ensheathing  layer,  namely  the  colon.  The  apex  remains 
the  same,  and  as  it  is  pushed  forward  by  peristalsis,  more  and 


INTUSSUSCEPTION  115 

more  of  the  sheath  is  drawn  in  to  allow  of  its  progression.  The 
returning  layer  becomes  creased  and  folded,  so  that  it  is  usually 
considerably  longer  than  the  two  others.  There  is  only  one 
exception  to  this  method  of  growth  of  an  intussusception,  and 
that  is  in  the  ileo-colic  variety,  in  which  the  ileum  prolapses 
through  the  ileo-csecal  valve.  As  the  condition  progresses, 
more  and  more  of  the  ileum  prolapses,  and  the  apex  thus  keeps 
changing,  the  intussusception  growing  entirely  at  the  expense 
of  the  entering  laj^er. 

As  the  intussusception  grows,  the  mesenter\'  is  dragged  in 
between  the  entering  and  returning  layer ;  as  a  result,  the  tumour 
becomes  curved  from  the  tension  of  the  mesentery.  Sooner  or 
later  the  mesentery  i~,  strangulated,  and,  in  consequence  of  its 
blood-supply  being  cut  off,  the  bowel  becomes  gangrenous. 

Etiology. 

It  seems  probable  that  the  normal  occurrence  of  anti- 
peristalsis  in  the  caecum  and  ascending  colon  has  an  important 
bearing  upon  the  causation  of  intussusception.  The  most 
common  form  is  that  in  which  the  ileum  passes  into  the  caecum 
and  colon,  and  it  is  obvious  that  antiperistalsis  in  the  colon 
would  tend  to  favour  such  a  condition  of  things,  as  at  one  period 
in  digestion  there  are  two  opposite  waves  of  peristalsis  occurring 
at  the  ileo-Ccecal  \-alve.  The  tendenc}-  would  be  for  the  smaller 
tube  to  become  invaginated  into  the  larger,  and  this  is  what 
occurs  in  intussusception.  But  since  antiperistalsis  of  the 
colon  is  a  normal  condition  occurring  many  times  a  day,  and 
intussusception  is  a  rare  pathological  condition,  it  is  obvious 
that  some  other  factors  are  necessary  as  exciting  causes,  though 
a  predisposing  cause  normally  exists. 

There  has  within  recent  years  been  much  speculation  as  to 
the  causes  of  intussusception,  and  man}'  most  complicated 
explanations  have  been  put  forward. 

In  the  hope  of  obtaining  some  positi\'e  information  bearing 
upon  the  causes  of  this  curious  affection,  I  carried  out  a  number 
of  experiments  upon  cats.  The  animals  were  kept  during  the 
whole  period  of  observation  under  an  anaesthetic  (ether).  The 
influence  of  the  anaesthetic  to  some  extent  interfered  with  the 
experiment ;  but  as  I  was  both  unable  and  unwilhng  to  carry 
out  the  experiments  otherwise  than  under  full  anaesthesia,  this 
had  to  be  ffot  over. 


ii6  INTUSSUSCEPTION 

I  found  that  if  the  animal  was  placed  in  a  tank  of  warm  saline 
solution  before  opening  the  abdomen,  and  if  ernutin  was  pre- 
viously injected,  the  anaesthesia  did  not  seriously  interfere  with 
the  movements  of  the  bowel. 

A  small  artificial  intussusception  was  produced  in  the,  bowel 
by  carefully  invaginating  a  portion  of  the  bowel  into  the  part 
below  it  with  forceps.  In  this  way  an  intussusception  in  a 
downward  direction  and  about  2  inches  long  was  produced. 
The  bowel  was  then  left  to  see  what  would  happen.  In  all 
cases  the  intussusception  reduced  itself  in  a  period  varying  from 
ten  to  thirty  minutes,  the  time  depending  upon  the  length  of 
the  intussusception.  This  was  tried  several  times  in  different 
cats,  but  always  with  the  same  result. 

The  experiment  was  then  tried  of  attempting  to  make  the 
intussusception  progressive  by  artificial  stimulation  of  the 
bowel  wall. 

An  intussusception  some  2  to  3  inches  long  was  produced  as 

A B 

c     i 


Fig.  39. 

before,  and  a  weak  faradic  current  was  applied  to  the  ensheathing 
layer.  The  stimulus  being  applied  at  A  in  Fig.  39,  the  result 
was  that  the  intussusception  rapidly  reduced  itself. 

When  the  stimulus  was  applied,  a  slight  contraction  occurred 
at  the  point  of  stimulation,  but  the  strongest  contraction  was  at 
the  point  B,  opposite  the  apex  of  the  intussusception  ;  from 
there  the  contraction  travelled  backwards  and  reduced  the 
invagination. 

Stimulation  of  the  entering  layer  at  C  produced  the  same 
effect,  namely,  strong  retrograde  contractions  at  B>  with 
reduction.  Wherever  the  stimulus  was  applied  the  effect  was. 
the  same,  namely  reduction  of  the  intussusception.  It  was  not 
possible  to  make  the  intussusception  progress  by  means  of 
stimulation  of  the  bowel  wall ;  the  effect  was  always  the  opposite,, 
namely,  rapid  reduction. 

Mechanical  stimuli,  by  touching  or  nipping  the  bowel,  were 


INTUSSUSCEPTION  117 

tried  in  place  of  the  electrical  stimulus,  but  the  effect  was  the 
same.  In  some  cases  a  slight  contraction  occurred  at  A,  but 
within  a  few  seconds,  a  second  and  stronger  ring  of  contraction 
occurred  at  B,  and  passed  backwards  until  the  intussusception 
was  reduced. 

I  then  tried  making  an  artificial  retrograde  intussusception  in 
the  colon  ;  this  soon  reduced  itself  if  left  alone,  and,  if  stimu- 
lated, reduced  itself  more  quickly. 

I  found,  in  fact,  that  in  a  normal  bowel  wall  an  intussusception 
tended  to  reduce  itself  and  not  to  be  progressive,  even  when 
violent  contraction  occurred. 

These  experiments  go  to  prove  that  an  intussusception 
cannot  occur  in  a  normal  bowel,  but  that  some  other  factor 
must  be  present. 

My  experiments  do  not  agree  with  those  of  Nothnagel,  who 
said  that  he  obtained  artificial  intussusceptions  by  tetanizing 
rabbits'  intestine  with  electrodes.  Experiments  on  the  same 
lines  carried  out  by  myself  have  absolutely  failed  to  produce  a 
similar  result. 

The  real  explanation  of  intussusception  seems  to  be  clearly 
shown  where  a  polypus  is  the  starting-point  of  the  invagination. 
The  polypus  acts  as  a  foreign  body  and  stimulates  the  bowel  to 
pass  it  on  ;  being  attached  to  the  bowel  wall  by  a  pedicle,  it  pulls 
this  in  after  it,  and,  as  the  polypus  is  carried  further  and  further 
down  the  bowel,  more  bowel  wall  is  drawn  in,  and  intussusception 
is  produced.  It  seems  probable  that  this  is  the  real  explanation 
in  all  cases.  True,  a  poh'pus  is  not  always  present,  but  some 
other  lesion  is,  which  acts  in  the  same  wa3'.  Cases  in  which  a 
polypus  forms  the  apex  of  an  intussusception  are  easily  explained 
by  this  view,  but  it  is  not  so  easy  to  account  for  the  common 
ileo-Ccecal  form  met  with  in  infants. 

The  late  Mr.  Barnard  attempted  this  b}'  assuming  that  pro- 
lapse of  the  ileum  occurs  through  the  ileo-caecal  valve,  in  the 
same  way  that  prolapse  of  the  rectum  takes  place  through  the 
anal  sphincter.  Prolapse  of  the  rectum  is  common  in  children, 
and  he  beheved  that  prolapse  through  the  ileo-csecal  valve  is  also 
often  present  in  children  under  similar  conditions.  He  argued 
that  the  prolapse  acts  like  a  foreign  body  in  originating  the 
intussusception.  There  are,  however,  several  facts  opposed  to 
this  view. 

Prolapse  of  the  rectum  usually  occurs  in  children  who  have 


ii8 


INTUSSUSCEPTION 


been  neglected,  who  are  thin,  badly  nourished,  or  recovering 
from  illness,  such  as  measles  and  whooping-cough,  or  it  follows 
infantile  diarrhoea. 


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57  35  58  45  44  41  57  33  18  25  29  5' 

Tot.al  453. 

Fig.  40. — Chart  showing  seasonal'  incidence  of  intussusceptions  in  453  cases  not  older  than  is 
months.      (FitziviUiams.) 


MOkTHS  YEARS 

1   2  3  ,4  5  6   7  8  9    101  II2I3MZ  3  4  5  6  7  8  9101  I    12 


85     . 

80 

75 

70 

65 

60 

55 

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5 
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1                        \/                V     .-^ 

ifllt            ^           ^^^  ^- 

Fig.  41. — Chart  showing  age  incidence  in  months  and  years  in  64S  cases  under  12  years  of  age. 

( Fitz-duilliams. ) 

Almost   without    exception,    however,    the    infants   who    get 
intussusception   are  well  nourished,   fat,   sturdy  children,  who, 


INTUSSUSCEPTION  119 

until  the  illness  began,  were  in  perfect  health.  Also,  if  intussus- 
ception resulted  from  prolapse,  one  would  expect  it  to  be  common 
at  those  times  of  the  year  when  diarrhoea  is  common,  as  is  rectal 
prolapse  in  children.  This  is,  however,  far  from  being  the  case. 
Mr.  Fitzwilliams,  in  a  recent  paper,*  analysed  453  cases  accord- 
ing to  the  time  of  the  year  at  which  they  occurred.  The  chart 
{Fig.  40)  shows  that  the  condition  is  commonest  during  March 
and  December,  and  least  common  in  August  and  September, 
the  months  during  which  diarrhoea  is  commonest.  FitzwiUiams 
has  pointed  out  that  March  and  December  (owing  to  Easter 
and  Christmas)  are  the  times  at  which  children  are  most  hkely 
to  overeat  themselves,   or  to  eat  indigestible  foods. 

While  the  prolapse  theory  does  not  seem  tenable,  the  following 
explanation  appears  to  be  possible  and  to  fit  all  the  facts.     If  a 


Fig.  42. — Diagram  showing  how  a  lump  of  indigestible  food  may  produce  an  intussusception 
by  becoming  impacted  in  the  ileo-caecal  valve. 

child  is  given  some  indigestible  food,  part  of  this  may  form  an 
indigestible  bolus  too  large  to  pass  through  the  ileo-caecal  valve. 
When  it  reaches  this  valve  it  either  becomes  impacted,  or  remains 
above  and  blocks  it.  Violent  peristalsis  will  then  occur  in  the 
ileum  above,  and  the  mass  being  unable  to  move,  the  whole 
ileo-caecal  valve  is  forced  into  the  caecum,  the  invagination  being 
aided  by  antiperistalsis  which  is  probably  occurring  in  the 
ascending  colon  and  caecum  as  the  result  of  food  which  has 
just  previously  passed  the  valve.  Lumps  of  undigested 
matter  are  commonly  found  in  the  apex  of  an  intussusception, 
and  when  they  are  not,  it  is  reasonable  to  suppose  that  they 
have  eventually  become  digested  or  have  been  squeezed  through 

*  Lancet,  February  29  and  March  7,   1908, 


120  INTUSSUSCEPTION 

the  valve.  This  explanation  fits  in  with  the  known  incidence 
of  the  condition  as  shown  by  Fitzwilliams,  and  also  with  the 
fact  that  the  ileo-caecal  variety  of  intussusception  is  so  much 
the  commonest. 

Fitzwilliams  suggests  that  the  most  probable  cause  of  this 
condition  in  infants  is  the  giving  of  unsuitable  food  before  the 
child  is  able  to  digest  it.  Such  food  as  crusts  and  biscuit  are 
often  given  with  the  false  idea  of  assisting  the  child  to  cut  his 
teeth.  There  is  every  reason  to  believe  this  to  be  the  correct 
explanation. 

Cancer  is  not  an  uncommon  cause  of  intussusception  in  the 
colon.  The  form  of  such  a  cancer  is  most  commonly  that  in 
which  the  growth  protrudes  into  the  bowel  lumen  and  forms  a 
polypoid  mass.  The  growth  in  such  cases  forms  the  apex  of  the 
invagination,  and  cases  are  on  record  in  which  a  growth  of  the 
sigmoid  or  descending  colon  has  projected  at  the  anus.  The 
late  Mr.  Barnard  describes  a  form  of  intussusception  which 
results  from  a  relaxed  or  paralyzed  condition  of  the  colon,  the 
healthy  bowel  invaginating  into  the  relaxed  portion.  This 
condition  usually  leads  to  a  chronic  form  of  intussusception 
with  chronic  constipation  rather  than  acute  obstruction.  Indeed, 
it  is  not  improbable  that  some  of  the  obscure  and  obstinate 
cases  of  chronic  constipation  result  from  a  recurring  intussus- 
ception of  this  nature. 

The  same  observer  also  described  a  very  rare  form  of  intussus- 
ception of  the  colon  which  originated  in  gangrene  of  the  trans- 
verse colon.  The  whole  of  the  gangrenous  portion  of  the  colon 
was  ultimately  passed  per  anum,  and  the  patient  recovered, 
with  a  stenosis  which  required  subsequent  operation. 

A  case  is  reported  by  Mr.  Ray,*  in  which  an  intussuscep- 
tion of  the  sigmoid  flexure  resulted  from  a  subserous  polypoid 
lipoma.  The  patient  was  a  woman  aged  30.  The  apex  of  the 
intussusception  protruded  from  the  anus.  The  patient  was 
operated  upon  and  the  polypus  successfully  removed. 

Pathology. 
In    acute    intussusception,    strangulation    soon     occurs    and 
the    invagination    becomes    irreducible.     The    blood-supply  of 
the    layers    forming    the    intussusception    is  interferred  with, 

*  Lancet,  March  4,   1905 


INTUSSUSCEPTION  121 

and,  as  a  result,  there  is  oedema  and  swelling,  which  still 
further  increases  the  strangulation  of  the  intussusceptum  or 
central  portion.  The  sheath  itself  seldom  suffers  much  damage, 
as  its  blood-supply  is  not  interfered  with  ;  the  chief  mischief 
occurs  in  the  middle  layer. 

The  first  serious  change  is  that  the  entering  and  returning 
layers  become  firmly  fixed  together.  This  occurs  first  near  the 
apex  of  the  invagination, — that  is  to  say,  at  the  part  which  is 
the  last  to  be  reduced,  the  result  being  to  make  the  intussus- 
ception irreducible.  First,  only  the  part  near  the  apex  is 
irreducible,  but  in  time  the  whole  may  become  so. 

Later  the  two  inner  layers  become  gangrenous.  This  usually 
occurs  first  at  the  neck,  where  the  collar  formed  by  the  turning 
over  of  the  ensheathing  layer  constricts  the  entering  layer. 
The  time  before  gangrene  may  appear  varies  in  different  cases. 
It  has  been  seen  in  thirty  hours,  but  more  usually  it  takes 
three  to  four  days,  and  sometimes  much  longer. 

Death  as  a  rule  occurs  from  exhaustion  or  peritonitis.  The 
bowel  above  the  intussusception  does  not  usually  undergo  any 
marked  alteration  except  in  chronic  cases. 

In  chronic  cases  of  intussusception,  there  is  obstruction  but 
no  strangulation.  Even  the  obstruction  is  not  complete,  or 
at  least  is  intermittent.  If  the  condition  exists  for  a  long 
time,  the  usual  secondary  changes  will  be  found  in  the  bowel 
above,  namely,  dilatation  and  hypertrophy.  Ulceration  may 
also  occur  both  in  the  intussusception  and  in  the  bowel 
above  it. 

Spontaneous  Elimination  of  the  Intussusception. — This  occa- 
sionally occurs  owing  to  gangrene  at  the  neck  allowing  the 
invaginated  portion  of  the  bowel  to  become  free,  thus  restoring 
the  bowel  lumen,  and  allowing  the  separated  invagination  to 
be  passed  per  anum.  As  a  result  of  the  inflammation  around 
the  gangrenous  area  the  entering  layer  and  the  sheath  become 
fixed  together,  thus  restoring  the  continuity  of  the  bowel  after 
the  intussusception  has  been  cast  off.  Very  considerable  lengths 
of  bowel  may  in  this  way  be  ehminated,  and  cases  are  recorded 
in  which  as  much  as  3  feet  or  more  of  bowel  have  become 
separated  and  passed  in  the  stools. 

Spontaneous  cure  of  an  intussusception  may  thus  occur, 
but  it  does  not  do  so  in  more  than  about  i  per  cent  of  cases, 
and  recovery  is  doubtful  even  after  it  has  occurred. 


122  INTUSSUSCEPTION 

Symptoms. 

Intussusception  may  occur  at  any  age,  but  is  most  common 
in  early  infancy.  The  late  Mr.  Barnard,  from  a  study  of  187 
cases  taken  from  the  records  of  the  London  Hospital,  found 
that  72  per  cent  occurred  in  children  less  than  a  year  old, 
and  88  per  cent  in  children  under  10  years  of  age.  Mr.  Fitz- 
williams,  from  an  analysis  of  648  cases  occurring  in  children 
under  12  years  of  age,  found  that  72  per  cent  were  in 
those  under  12  months  old  ;  20  per  cent  between  the  ages 
of  I  and  6  years  ;  and  6  per  cent  between  the  ages  of  7  and  12 
years.  He  also  found  that  the  greatest  number  of  cases 
occurred  in  infants  between  the  4th  and  7th  months  of  life. 

The  condition  is  much  commoner  in  males  than  in  females, 
the  proportion  being  about  2  to  i.  Fitzwilliams'  statistics  give 
68  per  cent  males  and  32  per  cent  females,  figures  which  agree 
very  closely  with  those  of  other  observers. 

Cases  of  intussusception  divide  themselves  into  two  types  : 
(i)  Those  in  which  the  symptoms  are  acute  ;  and  (2)  Chronic 
cases,  in  which  symptoms  persist  for  a  considerable  time 
without  causing  death. 

Cases  of  the  latter  type  are  usually  seen  in  adults,  and  in  the 
common  form  of  intussusception  which  occurs  in  infants  the 
symptoms  are  almost  without  exception  acute. 

The  symptoms  in  the  acute  cases  are  well  marked  and  dis- 
tinctive, and  the  following  is  typical  of  the  variety  most  usually 
met  with  : — 

The  patient,  a  well-nourished  and  previously  healthy  infant, 
is  suddenly  seized  with  violent  colic  ;  it  begins  to  scream,  and 
shows  all  the  signs  of  acute  abdominal  pain.  It  lies  on  its  back 
with  its  knees  drawn  up,  screaming  with  pain,  and  refuses  to  be 
pacified.  The  child  usually  vomits  once  or  twice  immediately 
after  the  onset  of  the  pain.  Though  vomiting  is  a  common 
occurrence  at  first,  it  usually  does  not  continue,  and  is  not  a 
marked  feature  in  most  cases.  There  is  much  tenesmus  and 
straining,  and  the  child  passes  stools  consisting  principally,  and 
sometimes  entirely,  of  blood  and  mucus.  The  stools  look  like 
apple  jelly,  and  are  the  most  characteristic  feature  of  the  disease, 
and  the  one  upon  which  the  diagnosis  principally  depends. 
These  apple-jelly  stools  are  frequent,  and  their  passage  is  accom- 
panied by  much  straining.  An  examination  of  the  abdomen 
reveals  a  distinct  sausage-shaped  tumour  in  about  two-thirds  of 


INTUSSUSCEPTION  123 

the  cases.  If  the  diagnosis  is  in  doubt  and  nothing  can  be  felt,  an 
anaesthetic  should  be  administered,  when  a  tumour  will  usually 
be  easily  made  out :  it  is  sausage-shaped,  and  generally  situated 
either  in  the  right  iliac  fossa  or  across  the  abdomen  at  about 
the  level  of  the  umbilicus.  In  some  cases  the  apex  of  the  intus- 
susception can  be  felt  on  making  a  rectal  examination.  The 
condition  once  established  rapidly  gets  worse,  and  the  child 
soon  passes  into  a  dangerous  state,  with  collapse,  coldness  of 
the  extremities,  rapid  pulse,  and  distended  abdomen.  If  un- 
reheved,  a  fatal  result  generally  follows  in  from  two  to  eight 
days. 

The  typical  s3"mptoms  are  acute  abdominal  pain,  coming  on 
suddenly  and  accompanied  by  a  palpable  tumour  in  the  abdomen, 
and  blood  and  mucus  in  the  stools.  Such  symptoms  in  a  child 
are  characteristic  of  intussusception,  but  although  the  clinical 
picture  is  as  a  rule  well  marked,  considerable  variations  may 
occur.  Thus  the  condition  may  supervene  upon  an  attack  of 
diarrhoea  or  indigestion,  or  the  child  may  be  seen  before  any 
stool  containing  blood  has  been  passed. 

If  the  child  comes  under  observation  soon  after  the  onset  of 
the  illness,  it  may  be  difficult  to  make  a  correct  diagnosis,  though 
there  will  seldom  be  any  doubt  as  to  a  serious  abdominal  lesion 
being  present,  and  if  the  patient  is  watched  for  a  few  hours  the 
diagnosis  will  be  cleared  up. 

When  the  child  is  first  seen  after  the  condition  has  existed 
for  some  time,  there  will  be  marked  collapse,  with  paleness  and 
coldness  of  the  extremities,  the  face  will  be  drawn,  the  abdomen 
distended,  and  all  the  signs  of  impending  death  will  be  observed. 

The  diagnosis  is  generally  not  difficult.  It  depends  principally 
upon  being  able  to  feel  a  tumour  in  the  abdomen.  This  is  a 
positive  and  certain  sign.  If  there  is  doubt,  and  no  tumour  can 
be  felt,  an  anaesthetic  should  be  administered  and  the  abdomen 
carefully  examined  bimanually  with  one  finger  in  the  rectum. 

In  the  case  of  intussusception  in  adults,  and  chronic  intussus- 
ception, the  symptoms  vary  so  greatly  in  different  patients 
that  it  is  impossible  to  give  any  characteristic  symptoms  or  to 
lay  down  rules  by  which  the  condition  may  be  diagnosed.  The 
symptoms  are  those  of  intestinal  obstruction  coming  on  in- 
sidiously or  of  an  intermittent  character,  and  it  is  seldom  that 
an  exact  diagnosis  of  the  lesion  can  be  made  bej'ond  the  con- 
clusion that  some  lesion  is  present,  causing  obstruction. 


124  INTUSSUSCEPTION 

Treatment. 

Non-operative  Treatment. — The  proper  treatment  is  im- 
mediate operation.  Although  reduction  can  sometimes  be 
effected  by  the  injection  of  fluid  into  the  bowel  per  anum,  this 
method  is  very  uncertain.  It  only  succeeds  in  a  small  percent- 
age of  cases,  and  reduction  is  often  not  complete.  Failing  the 
possibility  of  immediate  operation,  it  should  be  attempted,  but 
if  an  operation  can  be  performed  it  is  useless  to  delay  operating 
while  injection  is  being  tried,  for  if  the  injection  method  fails, 
as  it  probably  will,  the  patient  will  be  in  a  less  favourable 
condition  for  operation  afterwards. 

The  Injection  Method  of  Reduction. — The  child  should  be 
anaesthetized,  and  placed  in  a  position  with  the  buttocks  well 
raised  on  a  cushion.  A  rectal  tube  is  then  introduced  into  the 
anus,  and  to  this  a  glass  funnel  and  tube  are  attached.  Warm 
water  is  the  best  fluid,  and  this  should  be  run  in  slowly  with  a 
drop  of  not  more  than  about  3  feet.  Gentle  manipulation  of 
the  tumour  through  the  abdominal  wall  will  assist  in  reduction. 
The  injection  may  need  to  be  repeated  before  reduction  is 
complete.  If  this  is  successfully  accomplished,  the  child  must 
be  carefully  watched  for  the  next  day  or  two  to  see  that  the 
intussusception  does  not  recur,  as  it  is  apt  to  do. 

Operative  Treatment. — The  abdomen  should  be  opened  near 
the  middle  line  as  a  rule,  but  this  will  depend  to  some  extent 
upon  the  variety  of  intussusception  present,  its  position,  and 
size.  If  the  intussusception  is  not  too  large  it  should  be  delivered 
through  the  abdominal  wound.  If  this  is  impossible  owing  to 
its  size,  it  should  be  partly  reduced  in  situ,  and  the  remainder 
then  delivered  before  reducing  the  last  portion.  The  greatest 
difficulty  is  generally  experienced  in  reducing  the  last  two  or 
three  inches,  and  if  possible  it  is  advisable  to  be  able  to  do  this 
outside  the  abdomen,  when  the  exact  condition  of  affairs  can 
be  seen  and  the  condition  of  the  bowel  better  observed. 

The  best  method  of  reduction  is  b}^  catching  hold  of  the  colon 
opposite  the  apex  of  the  intussusception  and  gradually  squeezing 
the  latter  back.  It  is  better  if  possible  to  avoid  pulling  upon 
the  entering  layer,  and  to  reduce  the  condition  entirely  by 
squeezing  back  the  apex  of  the  invagination.  In  reducing  the 
last  two  or  three  inches  it  is  necessar}^  to  use  the  greatest  care 
in  order  to  avoid  tearing  the  gut,  which  is  often  ver}'-  friable  at 
this  point. 


INTUSSUSCEPTION  125 

If  the  condition  can  be  completely  reduced,  and  the  gut  is  not 
too  much  injured  to  recover,  the  bowel  should  be  returned  into 
the  abdomen  and  the  latter  closed  as  quickly  as  possible. 

Intussusception  usually  occurs  in  very  young  children,  and 
success  depends  very  largely  upon  operating  rapidly,  and  getting 
the  small  patient  back  to  bed  with  as  little  delay  as  possible.  For 
the  first  few  hours  the  foot  of  the  bed  should  be  raised  on  blocks. 
Care  should  also  be  taken  to  see  that  the  child's  respiration  is 
not  embarrassed  by  heav}'  bedclothes  resting  upon  the  chest, 
since  the  breathing  is  already  to  some  extent  interfered  with  by 
the  abdominal  binder.  Nourishment  should  also  be  adminis- 
tered as  soon  as  possible,  either  by  the  mouth  or  rectum. 

When  reduction  is  not  possible,  or  the  bowel  is  too  much 
damaged  for  there  to  be  any  reasonable  hope  of  its  recovery,  it 
becomes  necessary  to  consider  what  is  to  be  done.  The  ideal 
method  is  to  excise  that  portion  of  bowel  containing  the 
intussusception  and  to  anastamose  the  ends.  The  difficulty  is 
that  in  most  cases  the  patient  is  not  in  a  condition  to  stand  so 
severe  and  prolonged  an  operation  as  this  necessitates. 

The  only  other  alternative  is  to  perform  colotomy,  either 
by  excising  the  intussusception  and  tying  a  Paul's  tube  into 
the  two  ends  of  the  bowel,  or  by  bringing  out  that  part  of  the 
intussusception  which  cannot  be  reduced,  and  after  stitching- 
it  to  the  skin,  opening  it. 

Much  will  depend  upon  the  circumstances  of  the  case  and  the 
skill  of  the  operator.  Except  in  adults  and  older  children,  most 
cases  of  irreducible  intussusception  die,  whatever  is  done. 
There  have,  however,  been  several  successful  operations  recorded 
in  which  resection  and  end-to-end  anastomosis  have  been  followed 
by  recovery. 

The  following  case  recorded  by  F.  W.  Collinson*  is  a  good 
instance  of  recovery  after  resection. 

Case. — The  patient  was  3  months  old.  Symptoms  of  intussus- 
ception had  been  present  for  seventeen  hours  ;  chloroform  was  ad- 
ministered and  the  abdomen  opened  in  the  middle  hne.  The 
intussusception  was  easily  reduced,  all  but  the  last  4  inches,  which 
were  irreducible  and  dusky  in  colour.  The  bowel  was  clamped 
above  and  below,  and  the  intussusception  resected.  The  parts 
removed  consisted  of  2  J  inches  of  the  ileum,  the  caecum,  and  part 
of  the  ascending  colon,  some  7  inches  in  all.     The  ends  of  the  divided 


*  Lancet,  October  19,   1907. 


126  INTUSSUSCEPTION 

bowel  were  brought  together  with  a  Robson's  bobbin  and  the 
abdomen  closed.  Two  and  a  half  hours  after  the  operation  the 
child  was  put  to  its  mother's  breast,  and  after  this,  feeding  was 
continued  every  three  hours.  The  bowels  acted  ten  hours  after 
operation.  The  bobbin  was  passed  on  the  fifth  day.  The  child 
made  an  uneventful  recovery. 

In  chronic  intussusception,  operation  is  the  only  treatment. 
The  greater  part  of  the  invagination  is  as  a  rule  easily  reduced, 
but  there  is  often  difficulty  in  reducing  the  last  portion,  and 
resection  in  some  form  has  to  be  done.  Resection  with  end-to- 
end  anastomosis  appears  to  give  the  best  results  and;  owing  to 
the  better  condition  of  the  patient  previous  to  operation,  is  not 
attended  by  so  high  a  mortality  as  in  the  acute  cases.  The 
lower  mortality  from  resection  in  chronic  cases  is  also  to  some 
extent  accounted  for  by  the  fact  that  the  patients  are  generally 
older. 

The  following  table  shows  the  results  of  resection  and  end-to- 
end  anastomosis  by  suture  in  7  chronic  cases  of  intussusception. 

Czerny  F  age   36  Died. 

M  ,,52  Recovered. 

M  ,,13  Recovered. 

Boif&n  M  ,,24  Recovered. 

Braun  F  ,,23  Recovered. 

Miiller  —         —  Died.     N.B. — 150  cms.  resected. 

Rosenthal!     F  ,,    35  Recovered.  N.B. — 60  cms.  resected. 

Prognosis. 

This  is  good  when  operation  is  performed  early  and  the 
intussusception  can  be  reduced.  It  is  bad  in  acute  cases 
when  more  than  twenty-four  hours  have  elapsed  since  the  onset 
of  the  condition,  and  when  reduction  is  impossible. 

REFERENCES. 

H.  L.  Barnard. — "Intestinal  Obstruction,"  Allbiitt  and  Rolleston's 
System  of  Medicine,  2nd  ed.  vol.  iii. 

C.  D.  L.  FiTzwiLLiAMS. — "The  Pathology  and  Etiologv  of  Intussuscep- 
tion, from  the  Study  of  1,000  Cases,"  Lancet,  Feb.  29  and  Mar. 
7,  1908. 


127 


Chapter    XI. 
CHRONIC   MUCOUS    OR   MEMBRANOUS    COLITIS. 

Chronic  mucous  or  membranous  colitis  is  a  name  given  to  a 
condition  of  which  the  chief  symptoms  are  an  excess  of  mucus 
in  the  stools,  accompanied  by  abdominal  pain,  usually  of  a 
paroxysmal  type.  The  condition  is  a  badly  defined  one,  and 
vaiious  names  have  been  given  it  by  different  writers.  To 
mention  only  a  few  :  it  has  been  described  as  colica  mucosa, 
membranous  or  mucous  diarrhoea,  entero-cohtis,  mucous  croup, 
enteritis  membranacea,  and  glutinous  diarrhoea.  All  these,  and 
several  others,  have  been  used  to  designate  what  is  without 
doubt  the  same  complaint. 

The  distinguishing  feature  of  the  condition  is  the  passage  in 
the  stools  of  mucus  in  abnormal  quantities.  Patients  in  whose 
stools  this  mucus  is  present,  usually  suffer  more  or  less  con- 
tinuoush'  from  abdominal  discomfort,  from  constipation  which 
is  often  extreme,  and  occasional^  in  the  more  severe  cases,' 
from  violent  colicky  abdominal  pain. 

This  gives  the  essential  features  of  a  condition  which  has  been 
described  as  a  disease  under  the  before-mentioned  names,  and 
about  which  much  has  been  written.  In  Germany  especially, 
long  theses  have  been  written  upon  it,  and  numerous  specula- 
tions have  been  made  as  to  its  causation.  Prof.  Nothnagel,  who 
was  one  of  the  first  to  describe  it,  believes  it  to  be  a  secretory 
neurosis  without  any  lesion  in  the  colon,  due  to  some  condition 
of  the  central  nervous  system.  He  claims  that  the  neurasthenia 
which  often  accompanies  the  disease  is  the  cause  of  it.  In  this 
view  Nothnagel  has  many  followers,  among  whom  may  be 
mentioned  Westphalen,  King,  Harrison,  Osier,  Weigert,  and 
others.  They  get  over  the  obvious  difficulty  that  it  is  some- 
times found  associated  with  definite  lesions  of  the  colon,  by 
putting  these  in  a  separate  class  and  calUng  them  secondary 
colitis.     The  condition  has  been  compared  to  croup  and  asthma. 


128  CHRONIC    MUCOUS    OR 

and  the  most  elaborate  theories  have  been  propounded  to 
account  for  the  various  symptoms  on  the  neurotic  theory. 

On  the  other  hand,  Von  Noorden,  Boas,  Tuttle,  the  author, 
and  other  writers  maintain  that  the  condition  is  a  real  colitis, 
with  definite  lesions  in  the  colon.  The  whole  subject  has  become 
much  confused,  and  the  various  hypotheses  are  so  conflicting 
that  it  is  difficult  to  unravel  the  truth. 

The  name  itself  is  confusing,  as  colitis,  if  it  means  anything, 
implies  inflammation,  the  existence  of  which  many  writers  deny. 

The  condition  has  been  variously  classified  and  divided  on 
every  kind  of  basis  ;  thus  we  find  one  writer  classifying  the 
condition  according  to  the  appearance  and  form  of  the  mucus 
present  in  the  stools,  while  another  divides  it  in  reference  to  its 
supposed  causes. 

Symptoms. 

Chronic  mucous  colitis  is  most  frequently  met  with  in 
women,  between  the  ages  of  twenty-five  and  forty.  It  is, 
however,  not  uncommon  in  men,  and  one  of  the  reasons  why 
it  is  more  frequently  seen  in  women  is  that  men  are  less  prone 
to  seek  medical  advice  on  account  of  vague  symptoms,  and 
consequently  the  less  severe  cases  are  often  not  diagnosed. 
Though  it  is  most  common  between  the  ages  of  twenty-five  and 
forty,  it  is  by  no  means  confined  to  this  period  of  life  ;  several 
cases  have  been  recorded  in  children  ten  years  of  age,  and  I 
have  seen  it  in  a  patient  of  eighty-two. 

The  most  characteristic  symptom  of  the  condition  is  the 
passage  of  mucus  in  the  stools,  and  it  is  this  which  provides  its 
name  and  often  first  draws  attention  to  it.  The  mucus  may  be 
present  in  the  lorm  of  shreds,  or  may  form  large  casts  of  the 
bowel.  I  have  seen  such  casts  over  a  foot  long,  and  the  patient 
on  seeing  the  casts  under  such  circumstances  is  often  much 
alarmed,  not  infrequently  imagining  that  she  has  passed  some 
curious  and  abnormally  large  worm.  The  amount  of  mucus 
present  in  the  stools  is  often  considerable,  and  they  sometimes 
consist  of  little  else. 

In  a  typical  case  the  symptoms  occur  periodically.  Previous 
to  an  attack  there  is  usually  a  period  of  constipation,  the  bowels 
for  some  weeks  becoming  more  and  more  difficult  to  relieve. 
This  is  followed  by  a  sudden  paroxysm  of  acute  abdominal 
pain.      The  patient  feels  ill,  and  has  severe  colic.      In   severe 


MEMBRANOUS    COLITIS  129 

cases  there  maybe  vomiting,  and  a  feeling  of  sickness  is  common. 
The  pain  continues  with  more  or  less  severity  for  from  twenty- 
four  hours  to  a  week.  I  have  seen  instances  in  which  it  was 
so  severe  as  to  necessitate  the  use  of  morphia,  and  to  prevent 
sleep,  and  where  the  sj'mptoms  have  been  mistaken  for  intestinal 
obstruction  or  appendicitis.  The  temperature,  however,  is 
usually  normal.  The  crisis  terminates  with  an  action  of  the 
bowels,  most  usually  with  diarrhoea.  Each  act  of  defaecation 
is,  as  a  rule,  accompanied  by  pain  and  tenesmus,  so  that  the 
patient  has  been  known  to  faint  at  stool.  The  first  stools 
passed  after  an  attack  consist  almost  entirely  of  mucus,  often 
in  the  form  of  casts  or  membranes.  When  the  bowels  act, 
the  abdominal  pain  passes  off  and  the  patient  is  better  for  a  time. 
In  some  patients  the  attacks  recur  as  often  as  once  a  month, 
in  others  only  twice  or  thrice  a  year.  Some  enjoy  fair  health 
in  the  intervals,  while  others  are  more  or  less  chronic  invalids. 
The  paroxysms  are  most  common  in  those  patients  who  pass 
casts  and  large  membranes,  and  it  seems  probable  that  the 
severe  pain  is  due  to  the  bowel  becoming  blocked  by  masses 
which  have  become  detached  from  the  mucous  membrane,  and 
to  the  violent  peristaltic  efforts  at  expulsion ;  it  ceases  as  soon 
as  the  membrane  has  been  got  rid  of. 

Many  patients  with  chronic  mucous  colitis,  however,  never 
have  these  attacks.  They  suffer  from  chronic  abdominal 
discomfort  rather  than  actual  pain,  and  mucus  is  more  or  less 
constantly  present  in  their  stools.  The  tongue  is  furred,  there 
is  a  feeling  of  discomfort  after  food,  and  great  mental  and 
general  depression. 

Flatulence  and  distention  are  common  symptoms,  and  there 
is  almost  invariably  severe  constipation  or  a  history  of  previous 
constipation. 

The  patient  has  generally  a  very  poor  appetite,  often  only 
being  able  to  eat  a  few  special  articles  of  diet.  One  of  my 
patients  had  practically  lived  on  milk  for  eighteen  months. 
As  already  mentioned,  constipation  is  the  rule.  It  is  often 
severe,  so  that  the  patient  is  only  able  to  relieve  the  bowels 
by  large  doses  of  aperients,  and  then  at  uncertain  and  infrequent 
intervals.  In  quite  a  number  of  cases,  however,  there  is  diar- 
rhoea, though  even  in  these  there  is  an  antecedent  history  of 
constipation.  I  have  seen  patients  who  had  as  many  as  sixteen 
and  twentv  stools  in  the  twenty-four  hours ;   but  the  diarrhoea  is 

9 


130  CHRONIC    MUCOUS    OR 

often  to  a  large  extent  spurious ;  that  is  to  say,  there  is  very  httle 
faecal  material,  but  the  stools  consist  of  a  small  quantit}^  often  not 
more  than  an  ounce,  of  mucus  and  water.  Therefore,  although 
the  bowels  may  be  acting  very  frequently,  the  actual  amount 
of  faecal  material  passed  is  often  much  below  the  normal.  This 
diarrhoea  is  sometimes  accompanied  by  considerable  pain  and 
tenesmus. 

There  is  often  considerable  loss  of  flesh,  and  the  patient  is 
generally  much  below  the  normal  weight.  It  is  not  uncommon 
for  a  patient  to  lose  a  couple  of  stone  in  the  course  of  a  few  months. 
This  loss  of  weight  is  perhaps  best  seen  where  there  is  diarrhoea. 

Mental  Condition. — This  varies  considerabty.  In  a  large 
percentage  of  cases  the  patient  is  markedly  neurotic.  She 
attaches  quite  undue  importance  to  her  condition,  and  can 
think  of  little  else.  Manj^  are  peevish  and  irritable  :  a  trouble 
to  themselves  and  to  all  about  them.  If,  as  is  often  the  case, 
they  have  sufficient  money  to  live  a  lazy  life,  they  spend  most 
of  their  time  in  bed  or  on  the  sofa,  and  in  travelHng  to  different 
health  resorts.  They  never  feel  well  or  are  comfortable,  and 
to  many  of  them  life  is  a  burden.  The 3^  sleep  badly,  and  can 
hardty  get  about  at  all.  So  marked  is  the  neurotic  element  in 
many  cases,  that  it  is  not  surprising  some  observers  have 
supposed  it  to  be  the  cause  of  the  condition.  These  cases  form 
one  of  the  worst  classes  of  chronic  invalids. 

There  are  a  number,  however,  in  which  the  other  symptoms 
are  well  marked,  but  the  patients  are  not  in  the  least  neurotic. 
I  have  met  with  several  such  cases  where  the  patient  refused 
to  give  way  to  the  symptoms,  but  got  about  as  usual,  and  lived 
a  busy  and  useful  hfe.  The  condition  is  one  which  is  naturally 
depressing,  and  it  is  no  cause  for  wonder,  therefore,  when  the 
patient  is  not  obliged  to  work,  the  symptoms  are  allowed  undue 
prominence,  and  neurosis  and  hypochondriasis  occur.  Examina- 
tion of  the  abdomen,  especially  during  an  acute  attack  of  pain, 
will  often  enable  the  colon — especially  the  descending  colon  and 
sigmoid — to  be  distinctly  felt  as  a  firm  ridge.  This  is  not 
because  the  colon  is  thickened,  but  because  it  is  in  a  state  of 
spasm,  sometimes  called  enterospasm.  If  it  could  be  seen,  it 
would  be  found  to  be  a  firm  tube  with  contracted  walls. 

The  Stools. — The  character  of  the  mucus  differs  considerably 
in  different  patients,  and  also  in  the  same  patient  at  different 
times.     It  may  appear  as  clear  slime  like  uncooked  white  of 


MEMBRANOUS    COLITIS  131 

egg,  or  as  small  clear  lumps  like  tapioca.  It  may  be  present 
as  whitish  shreds,  or  strands,  or  in  balls.  Or  again,  it  mav 
occur  in  long  tubular  casts,  either  complete  or  broken  up  into 
strips.  Sometimes  it  is  passed  almost  in  the  pure  state,  while 
at  others  it  is  more  or  less  mixed  and  discoloured  with  fsecal 
material.  If  these  shreds  are  washed  they  can  be  seen  to  consist 
of  laminated  layers  of  pure  mucin  mixed  with  epithehal  cells 
and  food  particles. 

The  stools  are  often  pale  in  colour,  owing  to  a  deficiency  in 
the  secretion  of  bile.  Blood  is  often  present  in  small  quantities, 
though  it  is  necessary  not  to  mistake  blood  from  internal 
haemorrhoids  for  that  from  the  colon.  I  have  found  blood  to 
be  present  in  about  60  per  cent  of  cases. 

Intestinal  sand  is  sometimes  present.  This  curious  material 
may  exist  in  quite  large  quantities,  and  when  first  passed  is 
of  a  reddish  colour,  almost  exactly  resembling  ordinary  sea  sand, 
but  afterwards  becoming  darker.  One  of  the  writer's  patients 
passed  as  much  as  two  ounces  of  sand  in  a  day,  but  this  is  more 
than  usual.  In  some  patients  it  is  always  present  in  the  stools, 
while  in  others  it  only  occurs  intermittently.  Faeces  containing 
this  sand  often  cause  considerable  bleeding,  from  the  scarifying 
action  on  the  mucous  membrane  during  their  passage.  Sand 
is  generally  only  present  in  the  more  severe  cases.  In  at 
least  one  case,  the  patient  also  passed  uric  acid  gravel  in  the 
urine.  The  composition  of  this  sand  is  approximately  as 
follows  : — ^Water  15  per  cent,  inorganic  matter  51  per  cent, 
organic  matter  34  per  cent.  The  inorganic  residue  contains 
salts  of  calcium,  magnesium,  phosphorus,  iron,  and  also  uro- 
bilin ;    the  chief  inorganic  constituent  is  calcium  phosphate. 

Examination  of  the  Patient. — This  should  be  thorough, 
and  should  include  a  careful  examination  of  the  stools  on  several 
different  occasions  ;  and,  if  possible,  a  specimen  of  faecal  material 
and  some  urine  should  be  sent  to  a  competent  pathologist 
for  examination  and  report.  Special  attention  should  be  paid 
to  seeing  if  there  is  blood  in  the  stools.  The  amount  of  undi- 
gested food  is  also  important,  and  if  there  is  diarrhoea  it  is  a 
good  plan  to  give  some  charcoal  with  the  breakfast  on  one  or 
two  occasions,  and  ascertain  when  this  is  first  seen  in  the  stools. 
The  abdomen  should  be  examined  as  regards  the  presence  of 
tumours,  thickening  of  the  bowel,  spasm,  etc.     Also  the  stomach 


132  CHRONIC    MUCOUS    OR 

should  be  percussed  to  ascertain  whether  any  marked  degree  of 
visceroptosis  exists.  After  this  the  patient  should  be  made  to 
stand  up,  and  the  abdomen  be  examined  for  weakness  of  the 
abdominal  walls.  The  rectum  should  be  examined,  and  a  careful 
sigmoidoscopic  search  made  to  ascertain  the  condition  of  the 
pelvic  colon.  This  last  is  essential ;  otherwise  the  diagnosis  is 
little  better  than  guesswork,  and  if  a  local  lesion  exists,  as  it 
usually  does,  it  will  almost  certainly  be  missed. 

Pathology   and   Etiology. 

Chronic  mucous  colitis  is  a  condition  the  very  name  and 
description  of  which  are  based  entirely  upon  its  clinical  sym- 
ptoms, and  it  is  very  difficult  to  deal  with  such  a  condition  upon 
a  purely  pathological  basis.  I  trust,  therefore,  that  I  shall  be  in 
part  excused  for  any  confusion  of  terms  or  misapplication  of 
names  which  may  occur  in  the  attempt  here  made  to  so  deal  with  it. 

Before  going  further  it  is  necessary  to  consider  Nothnagel's 
theory  that  the  condition  is  a  sensory  neurosis. 

The  Neurosis  Theory. — Nothnagel  maintained  that  no 
pathological  lesion  in  the  colon  could  be  found,  but  he  was. 
admittedly  unable  to  see  whether  such  a  lesion  was  present 
or  not,  with  the  exception  of  a  few  cases  in  which  the  patient 
died  from  some  intercurrent  disease  and  a  post-mortem  examin- 
ation was  possible.  In  five  such  cases,  which  will  be  referred 
to  later,  no  lesion  of  the  colon  was  found  in  one,  but  a 
lesion  was  present  in  the  remaining  four.  In  four  others  in 
which  a  post-mortem  examination  was  made  upon  patients 
who  had  suffered  from  mucous  colitis  at  some  period  during 
their  hves,  no  lesion  was  found.  These  cases  were  reported 
respectively  by  Rugez,  Edwards,  Osier,  and  Jagic.  Thus, 
out  of  a  total  of  nine  cases  in  which  a  post-mortem  examination 
was  made,  no  lesion  in  the  colon  was  found  in  live.  It  must 
also  be  taken  into  consideration  that  the  condition  is  not  itself 
fatal,  and  that  several  of  the  patients  had  not  had  symptoms 
of  cohtis  for  some  time  previous  to  death.  Even  as  negative 
evidence  this  is  not  strong. 

The  other  fact  which  Nothnagel  made  much  of  to  support  his 
theory  was  that  most  of  the  patients  are  neurotic.  But  typical 
cases  of  chronic  mucous  colitis  occur  in  which  there  is  no 
neurosis  ;  on  the  other  hand,  we  commonly  see  sufferers  from 
chronic    prolapsed    piles    or    some    similar    ailment,   who    have 


MEMBRANOUS    COLITIS  133 

become  markedly  neurotic,  but  we  should  not  think  of  arguing 
that  the  piles  were  caused  by  the  neurosis.  It  is  evident  that 
Nothnagel's  theory  with  regard  to  the  causation  of  chronic 
mucous  colitis  rests  upon  the  slenderest  evidence,  and  that  of  a 
purely  negative  character. 

It  is  impossible  to  arrive  at  any  satisfactor\'  conclusion  with 
regard  to  the  pathology  unless  definite  data  as  to  the  condition 
of  the  colon  are  obtainable.  Until  recently  such  data  were 
only  possible  after  a  post-mortem  examination  following  the 
death  of  the  patient  from  some  intercurrent  disease.  Lately, 
however,  the  surgeon  has  on  many  occasions  been  called  to 
operate  upon  these  cases,  and  an  opportunity  has  thus  been 
afforded  of  examining  the  colon  during  the  progress  of  the 
operation.  Also,  within  the  last  few  years,  the  introduction 
of  the  electric  sigmoidoscope  has  made  it  possible  to  examine 
the  interior  of  the  pelvic  colon  in  such  cases  and  to  see  the 
condition  of  its  walls. 

I  have  collected  eighty  cases  of  this  condition  in  which  data 
ha\-e  been  obtainable,  and  it  is  on  this  evidence  that  the  state- 
ments here  made  are  founded.  Hitherto  the  cases  of  chronic 
mucous  colitis  collected  by  different  writers  have  been  taken 
indiscriminately,  and  in  the  majority  of  them  there  is  no  evidence 
whatever  of  the  condition  of  the  colon.  This  is  true  of  the 
collected  cases  of  Hale  White,  Von  Noorden,  and  Harrison, 
and  these  series,  though  of  value  from  the  clinical  aspect,  are 
useless  from  the  pathological. 

In  the  series  here  given  of  80  cases,  only  those  have  been 
taken  in  which  either  some  lesion  of  the  colon  was  found  to  be 
present,  or  in  which  such  a  lesion  was  more  or  less  definitely 
excluded  either  by  post-mortem  examination  or  by  operation. 

Cases  in  which  a  Post-mortem  Examination  was  made. 

Rothmann  .  .  .  .  An  inflammatory  condition  of  the 
mucous  membrane  of  the  colon 
was  found. 

Abercrombie  .  .      There  was  a  chronic  cystic  condition 

of  the  whole  mucosa  of  the  colon. 

Hemmeter  (2  cases).  A  histological  examination  of  the 
wall  of  the  colon  showed  chronic 
inflammation  of  the  mucosa. 

Weigart.  \ 

Osier.  No    pathological   condition    of    the 

Edwards  (2  cases).  colon  was  discovered. 

Jagic.  ) 


134  CHRONIC    MUCOUS    OR 

Of  the  cases  which  I  have  collected,  I  will  take  those  first  in 
which  no  cause  for  the  condition  was  discovered.  There  are 
14  such  cases. 

In  four,  no  lesion  was  found,  but  blood  was  present  in  the  stools 
in  addition  to  the  mucus.  Now  bleeding  cannot  occur  without 
an  abrasion  of  the  mucous  membrane  or  some  pathological 
condition  ;  it  is  therefore  certain  that  some  lesion  did  exist 
in  the  colon  in  these  cases,  though  at  the  operation  nothing 
abnormal  was  noticed. 

In  none  of  the  remaining  ten  cases  was  the  whole  colon 
thoroughly  examined,  and  they  cannot,  therefore,  be  taken  as 
certain  evidence  that  no  lesion  was  present. 

In  all  the  other  66  cases  a  definite  lesion  was  known  to  be 
present.     The  nature  of  the  lesion  varied  considerably. 

Cases. 
Adhesions  and  pericoHtis  causing  more  or  less 

kinking  and  obstruction.  .  .  .  .  .  14 

Enteroptosis  of  the  colon     .  .  .  .  .  .  5 

Chronic  appendicitis  .  .  .  .  .  .  5 

Inflammation   or    displacement    of   the   uterus 

or  appendag^es   .  .  .  .  .  .  .  .  2 

Previous    operations  upon    the    abdomen    and 

involving  the  colon  .  .  .  .  .  .  2 

Chronic  inflammation  of  the  colon    .  .  .  .  30 

Cancer     .  .  .  .  . .  . .  . .  7 

Fibrous  stricture  of  sigmoid  .  .  .  .  i 

In  two  cases  there  was  old  pelvic  cellulitis  and  the  sigmoid 
flexure  was  involved  in  the  adhesions.  In  one  case  an  abscess 
had  burst  into  the  colon  two  years  previously,  and  much 
thickening  round  the  sigmoid  flexure  could  be  felt.  There  was 
also  blood  in  the  stools.  One  patient  had  had  a  previous 
attack  of  gall-stones,  accompanied  by  local  peritonitis  in  the 
neighbourhood  of  the  gall-bladder. 

In  two,  the  colitis  began  after  a  severe  attack  of  gastric  ulcer 
from  which  the  patient  had  recovered  without  operation.  One 
of  these  patients,  a  woman,  age  45,  was  subsequently  operated 
upon,  and  extensive  adhesions  were  found  binding  the  stomach, 
great  omentum,  and  transverse  colon  so  firmly  to  the  anterior 
abdominal  wall,  that  they  could  not  be  separated  without 
serious  risk  of  tearing  the  bowel.  One  patient  had  had  a  large 
abscess  in  the  back  of  the  pelvis  opened  and  drained  through 
the  abdominal  wall,  and  the  colitis  dated  from  this.    ■  In  three. 


MEMBRANOUS    COLITIS  135 

the  sigmoid  flexure  was  found  to  be  bound  down  and  kinked 
by  a  band  of  adhesions. 

In  several  of  the  cases  there  was  definite  thickening  of  the 
cohc  wall,  or  chronic  inflammation  of  the  mucosa,  in  addition 
to  the  adhesions. 

The  adhesions  seem  indirectly  to  cause  the  increased  mucus 
and  membrane  in  the  stools  by  kinking  or  narrowing  the  colon. 
This  results  in  the  faecal  contents  passing  slowly,  or  being 
temporarily  retarded,  with  consequent  local  irritation  and 
inflammation  of  the  mucosa. 

Enteroptosis  is  only  an  indirect  cause  of  colitis,  and  should 
rather  be  considered  as  giving  rise  to  the  constipation  to  which 
the  colitis  is  secondary.  Some  of  the  worst  cases  of  membranous 
colitis  that  I  have  seen,  have  been  due  to  enteroptosis.  Not 
only  is  the  mesocolon  lengthened,  allowing  the  colon  to  fall  into 
the  lower  part  of  the  abdomen,  but  the  colic  wall  itself  shows 
well-marked  changes:  it  is  thinned  and  dilated,  often  to  a  con- 
siderable extent.  The  normal  pouching  is  much  increased,  and 
the  wall  bulges  between  the  longitudinal  muscle-bands.  If 
the  interior  of  the  sigmoid  is  examined  with  the  sigmoidoscope, 
the  walls  can  be  seen  to  bulge  inwards  in  such  a  way  that  they 
tend  to  prolapse  into  the  part  of  the  bowel  immediately  below. 

In  two  of  my  cases,  both  women,  the  centre  of  the  transverse 
colon  lay  in  Douglas's  pouch ;  and  in  one,  the  centre  of  the 
sigmoid  flexure  could  reach  the  edge  of  the  liver.  As  one  would 
naturally  suppose,  severe  constipation  accompanied  the 
condition. 

Chronic  Appendicitis. — There  has  been  much  discussion  as 
to  the  relationship  between  this  and  chronic  colitis.  That  the 
two  conditions  are  frequently  associated  there  can  be  no  doubt. 
Colitis  not  uncommonly  results  from  chronic  inflammation  of 
the  appendix,  or  the  two  may  occur  together,  the  one  complicating 
the  other.  There  is  very  positive  evidence  that  chronic  appendi- 
citis may  cause  colitis.  Mr.  Lockwood  has  recently  recorded 
three  cases  of  colitis  in  which  the  removal  of  a  chronically 
inflamed  appendix  resulted  at  once  in  the  disappearance  of 
all  the  cohtis  symptoms  ;  in  each  of  the  cases  the  appendix 
contained  septic  material  which  periodically  escaped  into  the 
caecum.  In  five  of  my  collected  cases,  a  chronically  inflamed 
appendix  was  found,  and  its  removal  resulted  in  the  disappear- 
ance of  the  colitis.     In  three  of  these,  large  mucous  casts  had 


136  CHRONIC    MUCOUS    OR 

previously  been  passed,  and  this  is  of  interest,  because  some 
writers  attempt  to  draw  a  distinction  between  mucous  and 
membranous  colitis. 

A  certain  amount  of  colitis  must  almost  invariably  accompany 
chronic  appendicitis,  and  as  Lockwood  has  pointed  out,  it 
is  common  to  find  a  certain  amount  of  inflammation  of  the 
ascending  colon  when  operating  for  appendicitis. 

Chronic  appendicitis  can  apparently  give  rise  to  colitis  in 
three  ways  : — 

1.  By  the  inflammation  spreading  from  the  appendix  directly 
to  the  caecum,  ascending  colon,  and  transverse  colon  ;  we  have 
evidence  of  this  in  many  cases  of  chronic  appendicitis. 

2.  As  a  result  of  appendicitis,  adhesions  may  form  between 


Fig.  43. — Malignant   tumour  in  the  sigmoid   flexure,  which  gave  rise  to  symptoms 
of  colitis  as  seen  and  diagnosed  by  the  sigmoidoscope. 

the  appendix  or  caecum  and  other  parts  of  the  colon,  usually 
the  sigmoid.  These  adhesions,  by  constricting  the  lumen  of 
the  bowel,  either  directly  or  by  the  formation  of  kinks  and 
abnormal  angles,  may  result  in  a  local  inflammation  of  the 
mucosa,  which  spreads  to  other  portions  of  the  colon. 

3.  The  inflamed  appendix  acts  as  a  septic  focus  which  is 
constantly  discharging  septic  material  into  the  colon.  It  seems 
as  reasonable  to  consider  this  a  cause  of  colitis  as  to  consider 
gastric  ulcer  and  gastritis  a  result  of  septic  conditions  of  the 
mouth  and  teeth. 

Malignant  Disease. — In  seven  of  the  cases  the  colitis  was  found 
to  be  due  to  cancer  in  the  colon.  In  all  of  them  the  growth  was 
in  the  sigmoid  flexure.     In  three  the  membranous  casts  supposed 


PLATE    III 


Fi^.  A. 


Chronic  Colitis. — Sigmoidoscopic  appearance  of  the  pelvic  colon  in  two  cases. 

{Aiit/wr). 


MEMBRANOUS    COLITIS  137 

by  some  to  be  typical  of  the  neurotic  form  of  colitis  were  found 
in  the  stools.  In  all  of  these  cases  the  condition  had  been 
diagnosed  as  chronic  mucous  colitis.  In  six,  the  growth  was 
disco\-ered  on  examining  the  bowel  with  the  sigmoidoscope, 
and  in  one  case  appendicostomy  was  performed  for  supposed 
chronic  colitis,  the  patient  subsequently  developing  obstruction, 
which  drew  attention  to  a  cancer  of  the  sigmoid. 

Chronic  Inflammation  of  the  Colon. — In  thirty  of  the  cases 
the  cause  was  found  to  be  a  chronic  inflammatory  condition 
of  the  mucosa.  In  most  of  these  the  condition  of  the  mucosa 
was  directly  examined  by  means  of  the  sigmoidoscope.  In  all, 
a  true  colitis  was  present,  but  the  type  of  inflammation  differed. 

Hypertrophic  Colitis. — In  this  condition  the  mucous  mem- 
brane is  paler  than  normal,  and  considerably  swollen,  due 
to  submucous  oedema.  The  mucosa  tends  to  lie  in  folds  or 
concentric  rings,  and  to  prolapse  into  the  lumen  in  a  character- 
istic manner.  The  bowel  wall  appears  to  be  redundant,  and 
somewhat  resembles  a  series  of  short  intussusceptions  at  the 
part  under  observation.  This  condition  is  associated  with 
excessive  secretion  of  a  thick  glairy  mucus,  which  can  be  seen 
sticking  to  the  bowel  wall  in  long  bridges  or  loops.  The  reaction 
of  this  mucus  is  sometimes  acid. 

Granular  Colitis. — This  is  present  in  a  number  of  cases. 
The  granular  appearance  of  the  mucosa  is  often  very  marked, 
and  gives  it  a  curious  appearance  as  the  light  is  reflected 
from  each  little  swelling.  This  is  due  to  inflammation 
of  the  follicles  in  the  mucosa  ;  each  follicle  is  swollen,  and 
projects  above  the  general  surface.  The  condition  is  a  pre- 
cursor of  follicular  ulcerative  colitis,  and  it  is  not  uncommon  to 
find  that  some  of  the  follicles  have  broken  down  and  formed 
ulcers.  The  mucosa  is  inflamed  and  often  of  a  dusky- red  colour. 
In  several  of  the  cases  in  which  I  have  been  able  at  a  subsequent 
operation  to  examine  the  bowel  wall,  I  have  found  it  much 
thickened,  and  in  one  there  was  also  some  enlargement  of  the 
lymphatic  glands  in  the  mesosigmoid.     (See  Plate  III.) 

Chronic  Catarrhal  Colitis. — For  want  of  a  better,  this 
name  must  be  used,  as  there  is  no  particular  feature  to  differ- 
entiate this  form  of  inflammation.  Here  the  whole  visible 
mucous  membrane  can  be  seen  to  have  lost  its  normal  glistening 
appearance,  and  to  be  much  redder  than  the  normal  mucosa. 
In  a  well-marked  case  the  appearance  is  as  if  the  surface  had 


138  CHRONIC    MUCOUS    OR 

been  rubbed  off  with  sand-paper.  The  surface  bleeds  readily  if 
touched,  and  apart  from  this,  small  bleeding  areas  can  be  seen. 
Here  and  there  patches  of  yellow  membrane-like  mucus  can  be 
seen  adhering  tightly  to  the  mucosa  ;  and  if  these  are  wiped  off, 
the  subjacent  mucosa  will  bleed.  The  inflammation  is  not 
uniform,  but  is  always  best  marked  at  the  apices  of  the  folds, 
and  on  the  upper  surfaces  and  edges  of  the  valvulas  conniventes. 

The  appearance  of  the  mucosa  in  cases  of  colitis  bears  a 
close  and  remarkable  resemblance  to  the  inflammatory  conditions 
of  the  throat.  I  have  seen  the  exact  appearance  of  granular 
pharyngitis  in  the  sigmoid  flexure,  and  in  many  cases  of  colitis 
which  I  have  examined,  the  appearance  irresistibly  reminded 
me  of  what  is  usually  described  as  a  septic  sore  throat.  The 
condition  of  the  mucosa  in  colitis  varies  much,  even  in  the  same 
case.  At  one  time  the  mucosa  will  look  almost  normal,  while 
at  another  the  conditions  described  may  be  seen.  The  condition 
is  a  chronic  one,  but  the  degree  of  inflammation  varies  very 
much  from  time  to  time. 

Though  for  purposes  of  description  it  is  convenient  to  divide 
up  the  types  of  inflammation  seen  in  colitis,  it  is  not  unusual 
to  find  more  than  one  type  present  in  the  same  case.  Ulcers 
in  the  mucous  membrane  are  also  often  seen  in  colitis,  but  they 
will  be  dealt  with  in  considering  ulcerative  colitis. 

From  the  statistics  here  given  it  seems  safe  to  conclude  that, 
in  the  great  majority  of  cases  of  so-called  chronic  mucous  or 
membranous  colitis,  a  definite  pathological  cause  for  the 
symptoms  exists,  though  these  causes  are  of  widely  varying 
chaarcters  in  the  different  cases.  B.  V.  Beck,  in  Germany,  has 
come  to  a  similar  conclusion  from  the  study  of  a  large  number 
of  cases. 

A  careful  study  of  the  cases  which  I  have  collected,  and  of 
the  pathological  data  obtainable  in  cases  of  chronic  mucous  or 
membranous  colitis,  leads  inevitably  to  one  conclusion,  namely, 
that  mucous  and  membranous  colitis,  as  ordinarily  described 
in  text-books  and  medical  treatises,  is  not  a  disease,  and  has 
no  claim  to  be  considered  as  a  clinical  entity.  It  is  clearly  a 
collection  of  symptoms  which,  from  want  of  better  knowledge  as 
to  the  pathology  of  the  colon,  have  been  described  as  a  disease, 
whereas  in  fact  these  symptoms  may  be  due  to  many  different 
pathological  conditions  of  the  colon,  of  widely  different  characters. 


MEMBRANOUS    COLITIS  139 

The  name  mucous  or  membranous  colitis  should  not  be  used, 
as  it  depends  upon  the  presence  of  mucus  in  some  form  or 
other  in  the  stools  ;  and  as  I  have  already  shown,  there  is 
excess  of  mucus  in  a  great  variety  of  different  patho- 
logical states  of  the  colon  ;  and  further,  the  form  which 
the  mucus  takes,  whether  shreds,  casts,  or  membrane,  is  of  no 
real  or  pathological  importance,  membrane  and  casts  being 
merely  a  rarer  form  in  which  the  mucus  may  exist  in  the 
dejecta.     (See  Chapter  II.) 

The  name  chronic  colitis  should  be  retained,  but  should  be 
used  only  to  designate  those  cases  already  described  in  which 
a  definite  chronic  inflammatory  condition  of  the  mucous 
membrane  of  the  colon  is  known  or  supposed  to  be  present. 

The  word  colitis  means  inflammation  of  the  colon,  and  is 
therefore  correct  as  applied  to  those  cases,  but  is  not  correct 
if  the  condition  is  a  neurosis,  or  if  due  to  pathological  conditions 
not  dependent  upon  inflammation. 

Previous  writers  have  argued  that  chronic  colitis  is  a  neurosis 
because  in  certain  instances  no  lesion  can  be  found  in  the  colon, 
and  it  cannot  be  denied  that  there  are  such  instances,  though 
they  are  rare.  It  seems  most  reasonable  to  explain  such  cases 
as  being  those  in  which  imperfect  observation  has  failed  to 
find  the  cause,  which  nevertheless  did  exist,  rather  than  to 
assume  that  they  are  a  special  class  in  which  there  is  no  patho- 
logical lesion. 

But  even  if  we  admit  that  cases  occur  without  any  pathological 
lesion  in  or  around  the  colon  being  present,  it  is  not  correct  to 
describe  these  as  colitis,  and  thej^  should  not  be  included. 

Treatment. 

Non-operative  Treatment. — If  the  patient  is  seen  during 
an  attack,  it  will  be  necessary  first  to  relieve  the  acute  symptoms, 
and  especially  the  pain,  before  proceeding  to  deal  with  the  colitis. 
The  indication  is  to  empt}'  the  colon  of  the  contained  mucus. 
The  plan  I  have  found  most  satisfactory  is  to  first  give  a 
hj'podermic  injection  of  morphia,  in  order  to  reHeve  the  spasm 
and  pain,  and  then  to  administer  a  large  olive-oil  enema.  This 
should  be  given  very  slowly,  with  the  patient  in  the  left  Sims 
position,  and  about  a  pint  should  be  injected.  At  least  fifteen 
minutes  should  be  occupied  in  giving  the  enema,  and  when  it  is 
all  in,   the  patient  should  assume  the  knee-elbow  position  for 


140  CHRONIC     MUCOUS    OR 

a  few  minutes  to  allow  the  oil  to  run  well  up  into  the  colon. 
An  hour  or  two  later,  a  plain  warm-water  enema  of  about  two 
pints  should  be  given.  This  will  generally  result  in  bringing 
away  the  mucus,  and  will  terminate  the  attack ;  if  not,  it 
should  be  repeated. 

The  non-operative  treatment  of  chronic  mucous  colitis  consists 
in  getting  the  mucous  membrane  of  the  colon  back  into  a  normal 
state.  For  this  purpose  nothing  seems  better  than  injections 
of  olive  oil.  The  oil  should  not  be  used  as  an  enema,  but  should 
be  retained  as  long  as  possible,  in  order  that  it  may  act  as  a 
dressing  to  the  inflamed  mucous  membrane.  I  order  from  a 
half  to  one  pint  of  warm  olive-oil  to  be  injected  very  slowly  into 
the  rectum  at  bedtime.  After  assuming  the  knee-elbow  position 
for  a  few  minutes  in  order  that  the  oil  may  get  well  up  the  colon, 
the  patient  should  remain  quite  quiet  and,  if  possible,  retain 
the  oil  till  next  morning.  If  it  is  properly  administered,  most 
patients  will  easily  retain  half  a  pint,  and  I  have  known  several 
who,  after  they  had  become  accustomed  to  the  injections,  could 
retain  a  pint  all  night.  Next  morning  a  warm  water  enema 
is  administered.  Under  this  treatment  the  colitis  often  quickly 
clears  up,  and  the  mucous  membrane  soon  assumes  a  healthy 
appearance.  Sometimes  it  will  be  found  that  some  stimulating 
application  is  needed,  as  the  mucous  membrane  remains  in  a 
chronically  inflamed  condition  in  spite  of  the  oil.  The  best 
injections  under  such  circumstances  are  protargol  or  argyrol 
in  ^  per  cent  solutions.  Nitrate  of  silver  should  never  be  used, 
as  it  causes  severe  burning  pain  and  does  no  more  good  than 
the  albuminates  of  silver,  which  are  painless. 

When  protargol  is  used,  it  should  be  given  in  place  of  the  oil, 
and  the  bowel  should  first  of  all  be  washed  out  with  warm  water. 
The  injections  should  be  made  with  a  No.  lo  soft  rubber  catheter 
and  a  glass  funnel,  not  with  a  syringe.  It  is  most  important 
in  cases  of  chronic  colitis  to  treat  the  constipation  which  almost 
invariably  accompanies  it.  While  the  oil  is  being  administered, 
the  bowels  will  act  without  difficulty,  however,  and  no  aperients 
should  be  given. 

Personally,  I  believe  it  is  better  not  to  administer  aperients 
at  all  in  cases  of  chronic  colitis  if  they  can  possibly  be  avoided, 
as  they  help  to  keep  up  the  condition.  The  best  aperient  is 
castor  oil,  if  one  has  to  be  given.  Dr.  Hale  White  believes 
in  treating  colitis  by  half-ounce  doses  of  castor  oil  administered 


MEMBRANOUS    COLITIS  141 

on  waking  in  the  morning.  The  only  other  aperients  which  are 
allowable  are  sulphate  of  magnesia  and  small  doses  of  cascara. 
Metallic  aperients,  such  as  calomel,  should  on  no  account  be 
given,  because  they  increase  the  inflammation  of  the  mucosa 
and  aggravate  the  disease. 

Among  the  drugs  which  have  been  advocated  for  cohtis, 
mention  must  be  made  of  belladonna.  This  often  has  a  good 
effect  in  preventing  the  spasm  of  the  colon  which  is  so  common. 
The  following  antispasmodic  mixture  I  have  often  found  to  do 
good  in  cases  of  colitis  : — 


Tinct.  Hyoscyami 

3ss 

Tinct.   Belladonnae 

..      ni^-j 

Sodee  Bicarb. 

.  .    gr.  XX 

Tinct.  Zingiberis    .  . 

.  .       Tl[xv 

Spt.  Chloroformi    .  . 

.  .       ll[xx 

Aq.  Menth.  P:p.    .  . 

.  .     ad.3J 

Misce.     One  ounce  three  times  daily. 

Arsenic  in  full  doses  is  also  recommended,  and  seems  to  do  good 
in  some  cases. 

Diet. — The  old-fashioned  treatment  for  chronic  cohtis  was 
to  feed  the  patients  with  milk  and  easily  digested  slop  dietary, 
with  the  object  of  keeping  the  colon  empty.  This  is  a  mistake  ; 
the  normal  colon  is  never  empty,  and  there  is  no  object  in  trv'ing 
to  keep  it  so.  Moreover,  these  patients  require  feeding  up,  in 
order  that  their  general  condition  mav  improve,  and  it  is  most 
important  the}-  should  be  given  a  full  diet.  Von  Noorden  has, 
I  think,  proved  that  the  old  plan  was  a  mistake  ;  and  patients 
treated  with  his  form  of  dietary  certainly  do  much  better,  and 
the  colitis  clears  up  more  quickly,  than  was  the  case  with  the 
old  method. 

Von  Noorden's  principle  is  to  give  a  full  diet  containing  an 
excess  of  indigestible  residue  :  that  is  to  say,  cellulose  and  fibre. 
The  patient  should  have  plenty  of  vegetables  and  fruit,  brown 
whole-meal  bread  in  place  of  white  bread,  and  a  small  amount 
of  brown  meat.  The  diet  should  be  a  full  one,  in  fact  as  much 
as  the  patient  can  eat.  The  result  is,  of  course,  to  cause  copious 
faeces,  owing  to  the  large  amount  of  indigestible  material  in  the 
food.  If  such  a  diet  were  given  alone,  it  would  result  in  hard, 
firm  stools,  which  it  is  particularh'  desirable  to  avoid  :  to  get 
over  this,  therefore,  a  sufficient  quantity  of  fats  must  be  added 


142  CHRONIC    MUCOUS    OR 

to  ensure  the  faeces  not  becoming  formed.  The  ahmentary 
canal  can  only  absorb  a  very  hmited  amount  of  fat,  and  if, 
therefore,  an  excess  is  given,  the  remainder  will  pass  out  in  the 
fasces,  and,  as  fats  are  liquid  at  body  temperature,  will  prevent 
the  faeces  becoming  hard,  and  keep  them  soft  and  unirritating; 

The  amount  of  fat  required  must  be  gauged  by  the  stools, 
which  should  be  about  the  consistency  of  ointment,  and  should 
be  quite  unformed  when  passed. 

The  fat  is  best  given  as  butter,  milk,  fat  bacon,  and  cream. 
The  addition  of  about  two  ounces  of  thick  Devonshire  cream 
to  the  diet  will  in  most  cases  produce  the  desired  effect  upon 
the  stools.  In  some  patients  the  excess  of  fat  causes  biliousness 
and  indigestion,  and  on  this  account  they  are  unable  to  continue 
taking  it.  When  this  is  the  case  petroleum  should  be  substituted 
for  the  fat.  Petroleum,  in  the  form  of  "  Lenitol "  (Rouse  &  Co.), 
or  the  hquid  petroleum  of  the  B.P.,  can  easily  be  taken  by  the 
mouth,  as  it  is  quite  tasteless,  and  beyond  the  greasy  sensation 
is  not  unpleasant.  This  is  not  absorbed  in  its  passage  along 
the  alimentary  tract,  and  all  passes  out  as  it  goes  in.  If  the 
correct  quantity  is  given,  it  absolutely  prevents  any  solidification 
of  the  faeces.  In  most  persons,  three  teaspoonfuls  of  "Lenitol" 
by  the  mouth  in  the  24  hours  will  render  the  faeces  quite  soft  and 
unirritating,  but  the  exact  quantity  required  must  be  ascertained 
by  experiment.  Fat  is,  however,  better  than  petroleum  when  it 
can  be  taken,  as  it  helps  the  patient  to  increase  his  weight,  which 
is  very  desirable  in  most  cases. 

The  first  effects  of  Von  Noorden's  diet  are  often  to  cause 
discomfort  from  flatulence  and  indigestion.  In  some,  it  may 
even  cause  nausea.  This  is  hardly  surprising,  considering  that 
the  patient  as  a  rule  has  been  living  for  some  time  on  a  minimum 
of  food,  and  has  no  appetite.  These  unpleasant  symptoms, 
however,  soon  pass  off,  and  he  begins  to  see  the  benefit  of  the 
changed  dietary.  The  weight  rapidly  increases,  the  bowels 
begin  to  act  regularly,  and  there  is  a  steady  improvement  in 
the  general  health.  In  order  to  overcome  the  initial  discomforts 
which  often  result  from  the  diet,  and  to  prevent  the  patient 
giving  up  the  treatment,  it  is  advisable  to  keep  him  in  bed  at  the 
beginning,  and  to  order  gentle  abdominal  massage.  The 
massage  should  be  for  about  ten  minutes,  an  hour  after  each 
meal,  and  along  the  line  of  the  colon.  This  will  quite  prevent 
any  discomfort,  and  will  greatly  assist  the  action  of  the  bowels. 


MEMBRANOUS    COLITIS  143 

I  have  often  seen  patients,  who  for  years  had  never  had  an 
unassisted  action  of  the  bowels,  get  two  natural  motions  a  day 
directly  this  treatment  is  adopted.  As  a  rule  they  quickly 
get  accustomed  to  the  diet,  and  are  able  to  dispense  with  massage 
in  ten  days  or  a  fortnight  :  It  should  be  continued  for  some 
considerable  time,  not  stopped  directty  the  symptoms  disappear. 
No  aperients  should  be  allowed. 

Operative  Treatment. — This  condition,  like  so  many  others, 
is  one  of  those  in  which,  purely  medical  treatment  having  failed 
to  give  relief,  the  aid  of  surgery  has  of  recent  years  been  called  in. 

Hale  White  has  stated  that  in  many  cases  a  cure  cannot 
be  expected  from  medical  treatment,  and  that  in  one-third  no 
alleviation  of  the  condition  results  from  it.  Beck  goes  further, 
and  says  that  none  of  the  cases  treated  medically  are  cured. 
^^'hile  Beck  certainly  overstates  the  case,  there  is  no  doubt  that 
in  a  considerable  number  of  cases  the  surgeon  is  called  in 
because  medical  treatment  has  failed  to  do  any  good.  This 
failure  must  be  to  a  considerable  extent  attributed  to  the  fact 
that  the  cause  of  the  condition  has  not  been  found,  and  that, 
in  consequence,  the  appropriate  treatment  has  not  been  adopted  ; 
the  first  essential  of  treatment  in  these  cases  being  a  correct 
diagnosis  as  to  the  underlying  cause  of  the  symptoms.  As  I 
have  already  shown  in  discussing  the  pathology,  the  cause 
is  in  many  cases  one  which  can  only  be  dealt  with  bv  surgical 
operation. 

I  shall  here  only  discuss  the  treatment  of  cases  of  real 
chronic  cohtis  (i.e.,  where  an  inflammatory  condition  of  the 
colon  exists),  as  in  the  others  the  treatment  naturally  comes 
under  other  headings,  according  to  the  pathological  condition 
found,  the  obvious  indication  being  to  remove  the  cause  when- 
ever possible  ;  this  may  be  a  chronicall}-  inflamed  appendix, 
adhesions,  cancer,  disease  of  the  uterus  or  appendages,  etc. 
In  order  to  make  a  correct  diagnosis,  an  exploratory  laparotomy 
may  be  necessary,  and  in  this  case  the  operator  will  proceed  to 
deal  with  whatever  cause  is  found,  or  to  do  whate\'er  operation 
he  considers  advisable. 

The  first  pubHshed  operation  for  chronic  membranous 
colitis  was  done  at  the  suggestion  of  Dr.  Hale  White  by  Mr. 
Golding  Bird  in  1895,  though  apparently  the  first  operation 
performed  for  this  condition  was  by  Mr.  Keith  in  1894.  In 
both  the  operation  consisted  in  estabhshing  an  artificial  anus 


144  CHRONIC    MUCOUS    OR 

on  the  right  side,  in  order  to  deflect  the  faecal  current  and  give 
rest  to  the  colon. 

In  considering  the  surgical  treatment,  we  have  to  bear 
in  mind  that  the  condition  is  not  a  fatal  one  and  in  no  way 
threatens  life,  but  calls  for  treatment  on  account  of  the  disable- 
ment and  distress  it  causes.  Surgery  has  attempted  to  cure 
the  condition  in  two  ways  : — 

1.  By  deflecting  the  faecal  current  through  the  colon, 
so  as  to  give  the  latter  complete  rest. 

2.  By  establishing  an  opening  through  which  the  colon 
can  be  constantly  washed  out  and  kept  clean. 

Of  these,  the  first  was  the  method  adopted  in  all  the  earh' 
cases  operated  upon.  A  right-sided  colotomy  or  caecostomy 
was  performed,  and  the  faeces  thus  prevented  from  passing 
along  the  diseased  colon. 

In  the  first  case  operated  on  by  Mr.  Golding  Bird,  the 
patient  was  much  benefited  b}^  the  operation.  The  colotomy 
opening  was  closed  in  seven  weeks,  and  the  patient  appeared 
to  be  cured  of  her  .colitis.  But  five  weeks  later  she  died 
suddenly  from  peritonitis,  the  cause  of  which  was  not  discovered. 

I  have  found  records  of  six  cases  in  which  an  artificial  anus 
was  established  on  the  right  side,  in  five  cases  the  caecum 
being  opened  and  in  one  a  right  lumbar  colotomy  being  performed. 
In  all  these  the  symptoms  rapidly  and  completely  subsided  after 
the  colon  was  put  at  rest.  In  all  of  them  the  symptoms  had  been 
severe,  and  had  resisted  all  other  forms  of  treatment.  The 
artificial  anus  was  kept  open  for  varying  periods,  from  six  weeks 
to  three  years.  It  was  found  that  if  the  opening  was  closed 
too  soon,  the  symptoms  were  liable  to  return. 

In  one  of  Mr.  Golding  Bird's  cases  the  colotomy  was  closed 
in  a  year,  and  the  patient  remained  well  for  six  years  from  the 
original  operation,  but  then  relapsed.  In  two  cases,  the  patient 
was  quite  well  and  had  had  no  relapse  four  years  after  the 
operation  ;  the  others  were  well  up  to  periods  less  than  this. 
One  died,  as  already  mentioned. 

As  regards,  therefore,  a  cure  of  the  colitis,  right  inguinal 
colotomy  or  caecostomy  gives  very  good  results,  especially  if 
the  opening  is  maintained  for  some  time  ;  Hale  \Miite 
advises  that  it  should  be  left  open  at  least  a  year.  The  operation 
is,  however,  not  a  satisfactory  one,  and  has  been  but  little 
adopted.     A    right-sided    colotomy    is    a    most    objectionable 


MEMBRANOUS    COLITIS  145 

operation  to  the  patient  ;  the  faeces  are  fluid  and  cannot  be 
properl}-  controlled,  the  skin  becomes  excoriated,  and  most 
patients  would  prefer  the  colitis  to  the  discomforts  which 
necessaril}'  accompan\'  such  an  operation. 

The  opening  can  be  closed  again,  but  must  be  left  open 
for  many  months  if  it  is  to  be  of  any  use.  The  closure  is  not, 
moreover,  always  an  easj^  matter,  and  in  several  of  the  cases 
two,  and  even  three,  operations  have  had  to  be  performed 
before  the  opening  could  be  closed. 

To  get  over  these  objections,  and  still  give  rest  to  the  colon, 
ileo-sigmoidostomy  has  been  performed  with  the  object  of  short- 
circuiting  the  colon.  This  has  been  done  successfully  in  several 
cases.  B.  V.  Beck  has  performed  it  for  chronic  colitis  in  six 
cases.  The  results  w^ere  excellent  in  five,  but  in  the  sixth  the 
patient  died  as  the  result  of  a  Murphy's  button  having  been 
used  for  the  anastomosis.  This  operation  is  the  same  as  that 
which  Lane  has  performed  for  constipation,  and  it  is  possible 
that  some  of  his  cases  were  of  the  same  nature. 

Ileo-sigmoidostomy  is  much  to  be  preferred  to  a  right-sided 
colotom\',  but  is  severe  considering  the  nature  of  the  malady, 
and  has  the  further  objection  that  it  permanently  short-circuits 
the  colon,  and  the  normal  course  for  the  fsces  cannot  afterwards 
be  re-estabhshed.  There  is,  however,  considerable  difference 
of  opinion  as  to  whether  this  is  an  objection  or  not.  Also,  in 
many  cases  the  rectum  and  sigmoid  flexure  are  involved  in  the 
disease,  in  fact  are  often  the  most  diseased,  and  consequently 
the  operation  will  not  short-circuit  the  entire  diseased  area. 
Ileo-sigmoidostomy  is,  moreover,  for  other  reasons  an  unsatis- 
factory operation,  but  this  will  be  discussed  in  considering  that 
operation. 

Left  inguinal  colotomy  has  also  been  done  ;  but  this  operation 
has  nothing  to  recommend  it,  as  it  does  not  get  above  the  disease 
and  cannot,  therefore,  do  much  good.  The  objections  to  a 
right-sided  artificial  anus  in  these  cases  were  early  recognized, 
and  the  plan  of  making  a  valvular  opening  into  the  cscum, 
through  which  the  faeces  would  not  escape,  but  through  which 
the  colon  could  be  effectualh- washed  out,  was  tried.  Gibson  was 
one  of  the  first  to  perform  this  operation,  and  it  proved  quite 
satisfactory  as  regards  a  cure  of  the  cohtis.  Except  in  exceptional 
cases,  however,  it  has  been  replaced  by  the  operation  of  appendi- 
costomy,  by  which  the  same  object  is  more  readily  attained. 

10 


146  CHRONIC     MUCOUS     OR 

Appendicostomy  has  none  of  the  objections  of  right-sided 
colotomy,  and  the  results  of  this  operation  in  the  treatment  of 
chronic  cohtis  seem  to  be  equally  satisfactory. 

The  operation  is  practically  free  from  risk,  does  not  prevent 
the  patient  from  attending  to  his  ordinary  occupation,  and  does 
not  cause  any  discomfort  or  even  inconvenience.  It  is  therefore 
a  suitable  operation  in  these  cases.  I  have  collected  several 
cases  in  which  appendicostomy  was  performed  for  this  condition. 

Case. — A  man,  aged  35,  was  under  my  care  in  St.  Mark's 
Hospital  in  1907.  For  fifteen  months  he  had  been  suffering  from 
repeated  severe  attacks  of  pain  in  the  abdomen,  accompanied  by 
the  passage  of  much  mucus.  He  had  been  unable  to  follow  his 
occupation,  and  a  long  course  of  medical  treatment  had  given  him 
no  material  relief.  Appendicostomy  was  performed  and  the  colon 
washed  out  daily  with  two  pints  of  boracic  lotion,  and  later  with 
the  same  quantity  of  water.  Previous  to  operation,  the  colon 
could  be  seen  on  examination  with  the  sigmoidoscope  to  be  much 
inflamed,  and  in  several  places  ulcers  were  present.  After  the 
operation  his  symptoms  quickly  cleared  up,  and  a  month  later  all 
signs  of  inflammation  in  the  colon  had  disappeared.  He  left  the 
hospital  and  continued  the  irrigations  for  six  months  ;  meanwhile, 
however,  he  returned  to  his  occupation.  Three  months  after 
operation  he  had  gained  over  a  stone  in  weight  and  felt  quite  well. 
A  year  after  the  operation  he  was  still  quite  well,  and  had  had  no 
return  of  the  colitis.  The  opening  of  the  appendix  caused  him  no 
trouble,  and  he  was  advised  to  keep  it  open  for  some  months  longer. 
When  last  seen  a  few  months  ago  he  was  quite  well,  and  the  opening 
had  been  allowed  to  close. 

Case. — A  lady,  aged  32,  had  for  eight  years  been  a  complete 
invalid  owing  to  severe  intermittent  attacks  of  so-called  membranous 
colitis.  She  spent  most  of  her  time  in  bed,  was  highly  neurotic, 
and  had  lost  weight.  She  had  been  treated  by  different  dietaries, 
and  douches,  medicine,  and  electricity,  but  without  any  improve- 
ment. Sigmoidoscopy  showed  chronic  inflammation  of  the  mucous 
membrane. 

I  performed  exploratory  laparotomy,  which  revealed  some 
thickening  of  the  bowel  wall  and  adhesions  binding  down  the  sigmoid 
flexure.  The  latter  were  divided  and  appendicostomy  performed. 
The  colon  was  daily  irrigated  with  water,  and  the  patient  continued 
the  irrigation  for  herself  after  her  return  home.  She  rapidly  im- 
proved and  put  on  weight.  Six  months  later  she  was  quite  well, 
and  there  had  been  no  further  attacks  of  colitis  and  no  mucus  or 
membrane  in  the  stools.  I  heard  from  her  again  over  a  year  after 
the  operation ;  she  was  quite  well  and  had  had  no  return  of  the  colitis. 


MEMBRANOUS    COLITIS 


147 


This  case  is  of  particular  interest,  as  the  patient  previous  to 
operation  was  very  bad,  and  the  question  of  making  an  artificial 
anus  on  the  right  side  had  been  discussed.  A  complete  cure 
of  the  condition  resulted  from  the  operation,  and  has  remained 
permanent  up  to  the  present  time. 

I  have  collected  in  all  twenty  cases  in  which  appendicostomy 
was  performed  for  chronic  colitis.  These  include  six  cases  of 
my  own,  of  which  five  were  operated  upon  by  myself,  and  one 
by  another  surgeon  before  I  saw  the  case.  There  are  also 
fourteen  cases  collected  from  medical  records.  The  results  in 
these  cases  may  be  tabulated,  as  follows  : — 


Cases. 

Results. 

Remarks. 

Author 

6 

Cured 

4 

All  well  over  a  year 

Impro\ed 

I 

later.     There  were 

No  better 

I 

slight     temporary 
relapses     in      two 
cases. 

Edwards 

I 

Cured 

Tuttle 

0 

Cured 
Improved 

I 
I 

WiUis 

I 

Cured 

Keetley 

3 

Cured 

2 

Moynihan 

I 

Cured 

Armour 

I 

Cured 

Stretton 

3 

Cured 
Improved 
No  better 

I 
I 
I 

Grey 

T 

Recovered 

Slight     relapse     two 
years  later. 

Pringle 

I 

No  better 

In  13  out  of  the  20  cases  the  patients  were  cured  of  the 
colitis,  and  no  relapse  is  stated  to  have  occurred.  In  three  the 
patients  much  improved,  but  one  or  more  slight  and  temporary 
relapses  occurred  during  the  following  two  years.  In  three  the 
patients  were  no  better  after  the  operation,  and  one  was  too 
recent  to  form  any  opinion. 

The  three  cases  in  which  there  was  no  improvement  are 
worth  recording  in  detail.  The  first  was  a  lady,  aged  32,  who 
was  sent  to  me  by  her  medical  attendant  with  a  history  that 


148  CHRONIC    MUCOUS    OR 

appendicostomy  had  been  performed  for  chronic  cohtis  a 
year  previously,  but  that  she  had  not  been  any  better  since 
the  operation.  A  careful  examination  of  the  bowel  with  the 
sigmoidoscope  showed  no  signs  of  colitis,  and  I  came  to  the 
conclusion  that  she  had  some  lesion  in  the  hepatic  flexure  of 
the  colon,  probably  adhesions  from  an  old  gastric  ulcer.  She 
was  averse  to  any  further  operation. 

The  second  is  a  case,  reported  by  Mr.  Seton  Pringle,*  of 
a  labouring  man  with  severe  membranous  colitis,  on  whom 
appendicostomy  was  performed.  No  improvement  followed 
the  operation,  and  six  months  later  he  was  as  bad  as  before. 
An  examination  of  the  bowel  with  the  sigmoidoscope  showed 
no  colitis. 

Mr.  Stretton  reported  the  third  case.  The  patient  was  an 
elderly  woman,  on  whom  appendicostomy  was  performed  for 
symptoms  which  were  attributed  to  chronic  mucous  cohtis. 
No  improvement  followed  the  operation,  and  it  was  subsequently 
discovered  that  there  was  a  malignant  growth  in  the  sigmoid 
flexure  which  had  been  the  cause  of  the  symptoms.  It  thus 
seems  probable  that  the  cases  where  no  improvement  follows 
appendicostomy  are  those  in  which  a  wrong  diagnosis  has  been 
made  in  the  first  instance.  In  some  of  the  cases  in  which 
relapse  has  occurred,  this  has  apparently  been  due  to  the 
opening  being  closed  too  soon. 

From  these  instances,  few  as  they  are,  it  may,  I  think,  be 
fairly  concluded  that  in  appendicostomy  we  possess  a  very 
good  and  useful  means  of  treating  bad  cases  of  true  chronic 
colitis  which  will  not  respond  satisfactorily  to  medical  treat- 
ment ;  by  it  we  may  expect  to  obtain  a  cure  of  the  condition 
without  serious  risk,  and  without  inconvenience,  even  in  the 
worst  and  most  protracted  cases. 

I  purposely  say  true  chronic  colitis,  for  if  the  operation  is 
performed  without  a  correct  diagnosis  having  previously  been 
made,  and  therefore  on  patients  in  whom  the  symptoms  are 
due  to  some  gross  lesion  of  the  colon,  a  satisfactory  result  cannot 
be  expected.  Where  there  is  chronic  inflammation  of  the  colon,, 
a  good  result  may  confidently  be  expected  from  the  operation,, 
and  where  chronic  colitis  is  associated  with,  or  has  resulted 
from,  a  gross  lesion,  good  results  will  follow,  providing  the 
lesion  is  removed  or  remedied  at  the  same  time. 

*  Brit.  Med.  Jour.  1908,  vol.  ii,  p.  1713. 


MEMBRANOUS    COLITIS  149 

It  is  certainly  advisable  that  the  opening  should  not  be  closed 
too  hastily,  and  a  year,  or  even  longer,  is  not  too  much  to  allow 
before  permanently  closing  the  appendix.  The  disease  is  one 
which  is  particularly  liable  to  relapse,  even  after  long  periods 
of  complete  immunity  from  all  symptoms ;  and  as  the  operation 
cannot  readily  be  repeated,  it  is  advisable  to  retain  the  opening 
until  all  likelihood  of  a  relapse  has  passed. 

If  in  nine  months  after  the  operation  there  has  been  no 
recurrence  of  symptoms,  the  irrigations  may  be  discontinued, 
and  the  opening  allowed  to  close  of  itself.  This  it  will  do  in  a 
few  days  by  the  formation  of  a  thin  skin  over  the  externa 
opening.  In  this  condition  it  will  not  cause  the  slightest 
inconvenience,  and  if  later  there  should  arise  the  necessity  to 
re-open  it,  this  can  readily  be  done  by  the  introduction  of  a 
probe,  because  the  appendix  itself  will  not  have  closed. 

Many  people  seem  to  have  an  idea  that  appendicostomy 
results  in  an  objectionable  condition  somewhat  like  that  following 
colotomy.  This  is,  however,  not  the  case.  If  the  operation 
has  been  properly  performed,  there  is  nothing  but  a  small  and 
depressed  scar  in  the  abdominal  wall,  from  which  neither  faeces 
nor  mucus  escapes,  and  over  which  in  most  cases  it  is  not 
necessary  to  wear  anything  except  the  ordinary  underclothing. 
The  patient  should  be  quite  unaware  of  the  presence  of  any 
opening  except  when  using  it  for  irrigation,  and  it  does  not 
prevent  the  patient  living  an  ordinary  life.  For  details  of  the 
operation  the  reader  is  referred  to  the  chapter  on  appendi- 
costomy. 

All  kinds  of  fluids  have  been  used  for  the  purpose  of  irrigating 
the  colon,  and  in  three  cases  which  have  come  under  my 
observation,  symptoms  of  poisoning  have  resulted.  Two  were 
cases  of  boracic  acid  poisoning,  and  one  of  carboluria  from  the 
use  of  lysol.  Antiseptics  do  not  seem  to  be  necessary,  and 
some  of  the  best  results  have  been  attained  where  nothing  but 
plain  water  was  used  ;  when  patients  have  to  do  the  irrigation 
for  themselves,  this  is  much  to  be  preferred.  Silver  compounds, 
such  as  argyrol  or  protargol,  o'5  or  i  per  cent,  have  been  em- 
ployed, but  are  probably  unnecessary. 

In  conclusion,  it  may  be  said  that  the  first  essential  for 
successful  treatment  is  a  correct  diagnosis  :  this  necessitates 
an  examination  with  the  sigmoidoscope,  and  sometimes  may 
require    an    exploratory   laparotomy.     In    true    chronic    colitis 


150  CHRONIC    COLITIS 

appendicostomy  should  be  the  operation  of  choice  in  all  cases 
where  medical  treatment  has  failed. 

ENTEROSPASM. 

This  is  the  name  given  to  a  condition  in  which  there  is  a 
spasmodic  contraction  of  the  circular  muscle-fibres  in  some 
portion  of  the  colon.  The  contraction  of  the  colon  is  localized 
to  one  spot,  and  varies  from  one  to  several  inches  in  length. 
So  intense  is  the  constriction,  that  the  bowel  lumen  is  partly  or 
completely  closed,  and  symptoms  of  intestinal  obstruction 
occur.  The  condition  is  comparable  to  asthma  and  spasmodic 
stricture  of  the  urethra. 

It  is  only  recently  that  anything  positive  has  been  known 
about  this  curious  condition,  but  before  it  was  described,  many 
surgeons  had  met  with  cases  in  which  a  patient  with  all  the 
symptoms  of  intestinal  obstruction  had  been  operated  upon, 
and  on  opening  the  abdomen  no  obstruction  of  any  sort  was 
discovered  after  the  most  careful  search.  In  several  of  such 
cases  the  upper  part  of  the  colon  and  small  bowel  were  found 
distended,  and  the  lower  portion  of  the  colon  collapsed  and 
empty  ;  yet  no  obstruction  or  possible  cause  of  obstruction 
was  to  be  discovered  at  the  point  where  the  distended  and 
collapsed  bowel  joined.  These  cases  were  a  mystery,  but  it 
now  seems  probable  that  they  were  in  reality  instances  of 
enterospasm.  Although  enterospasm  was  first  suggested  as 
an  explanation  of  these  and  similar  cases  on  purely  negative 
evidence,  we  now  have  positive  proof  that  the  condition  actually 
occurs. 

In  not  a  few  cases  the  spasmodic  stricture  has  been  seen  and 
handled  during  an  operation  for  the  relief  of  intestinal  obstruction. 
Perhaps  the  best  instance  occurred  in  the  practice  of  my 
colleague,  Mr.  Swinford  Edwards.  The  patient  was  a  woman 
with  a  history  of  several  attacks  of  partial  obstruction  in  the 
colon.  Careful  palpation  of  the  abdomen  revealed  the  presence 
of  a  hard  swelling  apparently  in  the  sigmoid  flexure,  and  it  was 
thought  that  she  had  a  tumour  obstructing  this  portion  of  the 
colon.  It  was  decided  to  perform  laparotomy,  and,  if  possible, 
remove  the  growth.  On  opening  the  abdomen,  Mr.  Edwards 
was  unable  to  find  any  tumour,  and  the  sigmoid  flexure  appeared 
to  be  normal.  While,  however,  he  was  examining  it,  a  contrac- 
tion about  two  inches  in  length  appeared  in  the  sigmoid  flexure. 


ENTEROSPASM  151 

The  contracted  portion  was  hard,  and  might  easily  have  given 
the  impression  of  a  tumour  when  felt  through  the  abdominal 
wall.  The  contraction  disappeared  and  then  re-appeared  in 
the  same  place  while  the  colon  was  under  observation. 

I  have  also  had  a  similar  case  in  my  own  practice.  The 
patient  was  a  woman,  aged  39,  who  was  admitted  into  the 
hospital  for  attacks  of  intense  abdominal  pain  and  symptoms 
of  a  severe  colitis.  A  sausage-shaped  tumour  about  two  inches 
long  could  be  felt  in  the  region  of  the  sigmoid  flexure.  There 
was  constant  diarrhoea,  with  stools  consisting  of  blood  and 
mucus.  I  at  first  thought  there  was  a  growth  in  the  bowel 
which  had  caused  the  symptoms,  but  a  careful  examination 
revealed  the  fact  that  the  tumour  was  only  present  during 
attacks  of  abdominal  pain,  and  that  when  the  patient  was 
examined  between  the  attacks  no  tumour  could  be  felt.  This 
was  verified  by  repeated  examinations,  and  we  came  to  the 
conclusion  that  the  supposed  tumour  was  due  to  a  localized 
contraction  of  the  colon.  The  affected  portion  of  colon  always 
occupied  the  same  position,  and  was  appearently  of  the  same 
size.  There  was  tenderness  on  pressure  over  this  spot,  and  in 
view  of  this,  and  the  presence  of  blood  in  the  stools,  it  seemed 
probable  that  the  enterospasm  was  set  up  by  an  ulcer  in  the 
colon.  The  patient  was  treated  by  dietary  and  full  doses  of 
belladonna.  She  recovered,  and  left  the  hospital  free  from 
the  attacks  of  pain  from  which  she  had  previously  suffered. 

Etiology. 

The  patients  are  nearly  always  women  between  the  ages  of 
thirty  and  fifty,  and  usually  of  a  markedly  neurotic  type.  There 
is  a  history  of  hysteria,  or  other  symptoms  ascribed  to  neuras- 
thenia, in  almost  all  cases.  The  condition  is  closely  associated 
with  chronic  colitis,  and  I  have  never  met  with  a  case  in  which 
there  were  not  well-marked  symptoms  of  colitis. 

There  is  good  reason  to  suppose  that  the  spasm  is  set  up 
by  some  local  lesion  in  the  colon.  Thus  the  condition  is  always 
accompanied  by  a  chronic  colitis.  Moreover,  in  all  the  cases 
which  I  have  seen  or  been  able  to  find  recorded,  there  has  been 
blood  in  the  stools,  which  is  definite  evidence  of  ulceration 
somewhere  in  the  bowel.  The  fact  that  the  spasm  is  locahzed 
to  a  particular  portion  of  the  bowel  also  strongly  suggests  a 
local  irritative  cause. 


152  ENTEROSPASM 

The  condition  is  essentially  a  chronic  one,  and  there  is  usually 
a  history  of  attacks  of  abdominal  pain  dating  back  for  several 
years. 

Symptoms. 

The  most  marked  symptom  is  severe  abdominal  pain. '^ This 
usually  occurs  in  paroxysms,  which  commence  suddenly  without 
apparent  cause,  and  after  lasting  for  a  period  varying  from  a 
few  hours  to  several  days,  pass  off  equally  suddenly.  The 
pain  while  it  lasts  is  very  severe,  and  often  closely  resembles 
that  which  occurs  in  the  early  stages  of  peritonitis  or  acute 
intestinal  obstruction.  It  may  also  be  easily  mistaken  for 
renal  colic.  It  is  usually  well  localized  to  that  portion  of  the 
abdomen  in  which  the  contracted  area  of  colon  lies.  Vomiting 
not  infrequently  accompanies  the  pain,  and  may  be  well 
marked.  If  the  spasm  continues  for  any  length  of  time,  the 
abdomen  becomes  distended,  there  is  more  or  less  complete 
constipation,  and  the  patient's  condition  becomes  typical 
of  acute  intestinal  obstruction.  Either  as  the  result  of  the 
administration  of  morphia,  or  naturally,  the  attack  suddenly 
terminates,  the  bowels  act,  the  pain  stops,  and  in  a  few 
hours  the  patient  is  quite  well  again.  If  the  abdomen  is 
examined  during  an  attack,  it  is  often  possible  to  feel  the 
contracted  area  of  colon,  which  is  most  commonly  situated  in 
the  descending  colon  or  sigmoid  flexure. 

In  addition  to  the  symptoms  caused  by  the  enterospasm, 
there  are  usually  those  of  a  chronic  colitis.  The  stools  contain 
much  mucus  and  often  blood.  There  is  constipation  alternating 
with  periods  of  diarrhoea,  and  all  the  other  symptoms  usually 
associated  with  a  chronic  colitis.  In  the  more  severe  cases 
faecal  vomiting  and  visible  peristalsis  may  also  be  present. 

The  diagnosis  is  extremely  difficult.  The  condition  may  be 
suspected,  but  if  the  patient  is  first  seen  during  an  attack  it 
will  be  practically  impossible  to  be  certain  that  the  condition 
is  due  to  enterospasm.  The  greatest  difficulty  arises  in  deciding 
as  to  whether  or  not  an  operation  shall  be  performed.  Usually 
the  condition,  though  very  distressing,  is  not  serious,  but  the 
following  case,  reported  by  Dr.  Pendred,*  terminated  fatally. 

Case. — ^The  patient  was  a  querulous,  excitable  woman,  aged  57. 
For  the  preceding  three  years  she  had  suffered  from  time  to  time 

Brit.  Med.  Jour.,  May  29,  1909,  p.  1292. 


ENTEROSPASM  153 

from  colic,  with  vomiting  and  diarrhoea.  Latterly  these  attacks 
had  become  very  frequent  and  severe.  The  urine  showed  a  trace 
of  albumin,  and  she  complained  of  frequent  micturition.  During 
the  next  two  months,  in  spite  of  energetic  treatment,  she  had  much 
colic,  and  had  plainly  emaciated.  A  copious  bleeding  from  the 
rectum  occurred  about  this  time.  Month  after  month  she  continued 
to  waste,  and  had  constant  vomiting  attacks.  Constipation 
alternated  with  diarrhoea,  which  latter  somewhat  relieved  her  pain. 
In  July,  1905 — ten  months  after  she  was  first  seen — she  was 
nearly  bedridden  with  colic,  coming  on  every  few  minutes, 
accompanied  by  tremendous  borborygmi.  Visible  peristaltic  waves 
passed  across  coils  of  intestine  from  left  to  right  every  few  minutes, 
as  though  the  intestine  were  endeavouring  to  overcome  some 
obstruction.  By  the  end  of  this  month  her  condition  was  pitiable, 
and  she  had  to  be  kept  constantly  under  the  influence  of  morphine. 
The  pain  was  almost  constant  night  and  day.  The  vomit  now 
became  stercoraceous,  hiccough  supervened,  and  the  bowels  were 
confined.  On  July  29th  the  abdomen  was  opened,  but  at  first 
nothing  amiss  could  be  found.  At  one  point  the  distention  of  the 
gut  suddenly  ceased,  and  the  distal  portion  was  flat,  toneless,  and 
of  a  paler  colour,  so  that  it  was  thought  the  obstruction  had  been 
discovered.  WhUst  the  bowel  was  being  watched,  the  collapsed 
gut  began  to  fill  out  again,  just  as  it  had  appeared  to  do  through 
the  abdominal  wall.  Three  days  later  her  condition  was  as  bad  as 
ever,  the  gurgling,  peristalsis,  pain,  and  sickness,  with  occasional 
haematemesis,  being  nearly  continuous.  She  died  in  the  middle 
of  September.  A  post-mortem  examination  of  the  abdomen 
showed  that  every  organ,  though  wasted,  was  macroscopically 
healthy.  The  intestine  was  partly  opened  up,  and  presented  a 
normal  appearance. 

Treatment. 

The  obvious  treatment,  if  the  condition  can  be  diagnosed, 
is  to  give  a  full  dose  of  morphia  and  belladonna  to  allay  the 
spasm.  This  will  usually  quickly  terminate  the  attack.  Placing 
the  patient  in  a  hot  bath  will  also  often  have  a  similar  effect. 
But  the  key  to  the  situation  is  the  diagnosis,  and  it  is  often 
impossible  to  be  certain  that  we  are  not  dealing  with  a  strangu- 
lation of  the  bowel. 

If  the  condition  can  be  diagnosed,  further  attacks  may  be 
prevented  b\"  treating  the  colitis  and  by  administering  belladonna 
in  full  doses. 


154 


Chapter  XII. 
ULCERATIVE     COLITIS. 

Until  quite  recently  ulcerative  colitis  was  a  disease  of  the 
post-mortem  table  ;  it  was  seldom  diagnosed  during  life 
(with  the  exception  of  tropical  dysentery),  and  no  attempt 
had  been  made  to  deal  with  it  by  operative  surgery.  It  is  now, 
however,  beginning  to  be  recognized  that  ulceration  of  the 
colon  may  be  dealt  with  successfully,  and  already  there  are 
a  number  of  cases  on  record  in  which  the  disease  has  been  cured 
by  operation,  which  otherwise  would  almost  certainly  have 
ended  fatally. 

The  subject  of  ulcerative  colitis  is  surrounded  by  many 
difficulties.  Most  of  our  knowledge  of  the  morbid  appearances 
is  derived  from  post-mortem  examinations,  in  which  from  the 
nature  of  things  only  the  terminal  and  most  severe  characters 
of  the  disease  can  be  studied.  The  confusion  which  exists 
between  ulcerative  colitis  and  tropical  dysentery  is  as  yet  far 
from  being  cleared  up,  and  there  are  those  who  still  assert 
that  all  cases  of  ulcerative  colitis  are  examples  of  tropical 
dysentery. 

Ulceration  of  the  colon  resembles  that  of  the  skin,  inasmuch 
as  it  may  result  from  a  great  many  different  conditions  and 
occur  in  many  different  forms.  Thus  it  may  arise  secondarily 
to  some  constitutional  trouble,  such  as  Bright's  disease,  gout 
or  plumbism.  It  may  result  from  a  specific  infection,  as  in 
amoebic  dysentery,  Shiga's  bacillary  dysentery,  enteric  fever, 
tuberculosis,  and  possibly  syphilis.  It  may  occur  from 
malignant  disease,  or  as  the  result  of  hardened  and  long- 
retained  faecal  masses,  such  as  the  ulceration  caused  by  a 
stercolith,  or  in  the  dilated  bowel  above  a  stricture.  It  may 
follow  damage  to  the  blood-supply  of  the  colon,  as  in  some 
cases  of  cirrhosis  of  the  liver  and  in  embolism  of  the  mesenteric 
arteries.  Or  it  may  result  from  trophic  changes  due  to  inter- 
ference with  the  innervation  of  the  colon  ;    two  such  cases  are 


ULCERATIVE    COLITIS 


155 


recorded  by  Dr.  Hale  \Miite,  in  which  the  patient  had  a  fractured 
spine  and  paraplegia. 

Much  of  the  confusion  which  surrounds  the  subject  has  arisen 
from  the  fact  that  investigators  have  often  failed  to  sufficiently 
recognize  the  great  number  of  different  causes  of  ulceration 
in  the  colon,  and,  confusing  several  together,  have  attributed 
all  to  some  specific  cause. 

Ulcerative  colitis  has  been  considered  so  fatal  a  disease, 
apart  from  tropical  dysentery,  that  some  writers  have  main- 
tained it  cannot  be  recovered  from,  and  that  the  reported  cases 
of  recovery  were  not  true  ulcerative  colitis.  This  is  a  not 
uncommon  error  when  a  disease  is  studied  only  upon  the 
post-mortem  table  and  there  is  no  other  means  of  arriving 
at  a  correct   diagnosis.     A    study  of  the  recorded  cases  would 


Fig.  44. — Ulcers  in  the  sigmoid  flexure  in  a  case  of  chronic  constipation. 

certainly  lead  to  the  conclusion  that   the  disease,  except  in  its 
epidemic  form,  is  practically  always  fatal. 

The  sigmoidoscope,  however,  has  made  it  possible  to  diagnose 
ulcerative  colitis  with  certainty  without  a  post-mortem  examin- 
ation, and  it  is  now  obvious  that  the  disease  is  by  no  means 
incompatible  with  complete  recover}^  and  with  early  diagnosis 
and  suitable  operative  interference  there  is  good  reason  to  hope 
that  much  may  be  done  to  materially  lower  the  mortality. 

Etiology. 

The  disease  is  one  of  early  adult  life  ;  thus,  out  of  my  series 
of  60  cases,  the  average  age  is  37.  It  apparently  does  not  occur 
in  children,  with  the  exception  of  follicular  colitis. 


156  ULCERATIVE     COLITIS 

The  sexes  appear  to  be  equally  affected  ;  out  of  the  total 
of  177  cases  collected  from  different  London  hospitals  at  the 
time  of  the  discussion  on  ulcerative  colitis,  which  took  place 
in  January,  1909,  at  the  Royal  Society  of  Medicine,  89  were 
males  and  88  females. 

Bacteriology. 

Ulcerative  colitis  necessarily  includes  endemic  amoebic 
dysentery  and  epidemic  bacillary  dysentery,  or,  as  it  is  some- 
times called,  asylum  dysentery. 

The  former  is  a  well-marked  and  distinct  endemic  form  of 
ulcerative  colitis  which  does  not  occur  in  this  country,  and  for 
further  information  in  reference  to  it  the  reader  is  referred  to 
works  on  tropical  medicine. 

A  great  deal  of  work  has  recently  been  done  upon  the  subject 
of  bacillary  dysentery,  and  the  organisms  which  are  supposed 
to  cause  the  disease  have  been  separated.  The  most  important 
of  these  are  Shiga's  Bacillus  dysenteries,  and  Flexner's  acid 
bacillus.  They  have  not,  however,  fulfilled  Koch's  postulates, 
and  there  is  not  at  present  sufficient  proof  to  establish  the 
specific  bacteriological  origin  of  ulcerative  colitis.  Many 
investigators  have  maintained  that  chronic  ulcerative  colitis 
and  bacillary  dysentery  are  the  same  disease  ;  some  have  even 
gone  so  far  as  to  maintain  that  the  cases  of  chronic  ulcerative 
colitis  met  with  in  this  country  are  sporadic  cases  of  amoebic 
dysentery  ;  but  the  latter  is  certainly  not  true,  except,  perhaps, 
in  a  few  isolated  instances,  as  the  amoebae  cannot  be  demonstrated 
in  the  stools,  nor  do  the  cases  bear  any  but  a  superficial  clinical 
resemblance  to  cases  of  dysentery. 

Supporting  the  view  of  a  close  relationship  between  bacillary 
dysentery  and  chronic  ulcerative  colitis.  Dr.  Carver  has  pointed 
out  that,  both  at  the  Great  Northern  Hospital  in  1902,  and  at 
the  Westminster  Hospital  in  1903,  an  outbreak  of  acute  bacillary 
dysentery  followed  the  admission  into  these  hospitals  of  cases 
of  chronic  ulcerative  colitis.  As  yet,  however,  it  has  certainly 
not  been  proved  that  ulcerative  colitis  is  due  to  a  specific 
bacterial  infection,  and  it  is  at  present  impossible  to  say  whether 
the  organisms  discovered  in  the  ulcers  are  the  cause  of  the 
ulceration  or  are  a  secondary  infection.  Flexner  and  Sweet 
have  shown  that  in  cases  of  bacillary  dysentery  the  lesions  in 
the  colon  are  apparently  produced  by  the  elimination  of  toxins. 


PLATE    IV 


Fig.  A. — Chronic  Ulcekative  Colitis,  with  much  thickening  of  the  bowel-wall  and  a  granular 
condition  of  the  mucosa,  as  seen  through  the  sigmoidoscope. 


Fig.   B. 
Fig.  B. — Appearances  in  a  case  of  Follicular  Colitis. 


ULCERATIVE     COLITIS 


157 


The  toxins  are  excreted  chiefly  by  the  large  intestine,  and  it  is 
the  reaction  to  this  process  which  produces  the  lesions. 

Pathology. 

Many  different  types  of  ulceration  are  seen  in  the  colon,  and 
it  is  not  at  present  possible  to  say  whether  they  are  different 
kinds  of  ulceration,  or  only  different  degrees  of  the  same  type. 

In  some  cases  the  mucous  membrane  is  so  destroyed  by 
ulceration  that  little  normal  membrane  can  be  seen  anj^vhere 
in  the  entire  colon,  while  in  others  there  are  only  a  few  isolated 
ulcers  in  one  or  more  parts  of  it.  In  the  majority  of  cases  in 
which  a  post-mortem  examination  has  been  made,  the  entire 
colon  was  more  or  less  ulcerated.  In  most  of  the  records  I 
have  been  able  to  find,  the  colon  was  the  only  part   diseased. 


Fig.   45.— Ulcerative  colitis— sigmoidoscopic 

except   for   septic   lesions   such   as   abscess,    or    peritonitis,   the 
secondary  consequence  of  the  ulceration. 

The  lesions  vary  in  size,  from  quite  small,  punched-out  ulcers, 
the  size  of  a  pea,  up  to  large  irregular  tracts  covering  many 
inches.  When  examined  during  life  with  the  sigmoidoscope, 
the  edges  of  the  ulcers  can  be  seen  to  be  raised,  and  to  have 
a  bright  red  areola.  The  base  is  generally  covered  with  fine 
granulations,  and  there  is  often  either  white  adherent  mucus 
or  a  yellow  slough  adhering  to  the  surface.  These  sloughs, 
however,  quickly  become  detached  by  the  constant  diarrhoea, 
and  consequently  are  not  commonly  found  in  post-mortem 
specimens. 


-Df 


ULCERATIVE     COLITIS 


The  ulcers  are  most  often  seen,  and  appear  to  commence,  in 
the  hollows  of  the  bowel,  such  as  in  the  depressions  between 
the  valvulae  conniventes,  and  in  the  bases  of  the  saccuH.  When 
the  disease  is  extensive,  the  ulcers  tend  to  run  together,  and 
become  confluent,  so  that  they  assume  a  most  irregular  outUne. 
Small  islands  of  normal  mucosa  often  remain  in  places,  and 
stand  out  like  polj-pi  above  the  surrounding  ulceration ; 
similarly,  narrow  bands  or  bridges  of  mucous  membrane  may 
be  left  between  the  ulcers,  and  this  often  gives  the  bowel  a  most 
curious  appearance.  At  first  sight  it  appears  as  though  covered 
\\dth  polypi,  but  a  closer  inspection  shows  these  to  consist  of 
islands  of  swollen  mucous  membrane  surrounded  by  ulceration. 
In  some  cases  the  ulceration  has  spread  almost  uniform!}'  over 
the  bowel,  in  others  longitudinally,  leaving  long  ridges  of  normal 
mucosa  standing  above  the  surrounding  ulcerated  surface.  Again, 
the  ulceration  may  have  spread  circularh-. 

Occasionallv  the  ulcers  are  all  more  or  less  discrete,  though 
numerous,  and  the  appearance  is  as  if  the  mucosa  was  honey- 
combed or  trabeculated.  Thev  are  commonly  numerous,  and 
extend  throughout  the  greater  part,  if  not  the  whole,  of  the  colon  ; 
but  in  a  few  cases  there  have  been  not  more  than  one  or  two 
large  ulcers. 

The  depth  of  the  lesions  varies  considerablj- :  in  some  the 
mucosa  appears  as  if  scraped  or  sandpapered,  so  that  the  surface 
is  entirelv  removed.  This  condition  is  seen  in  cases  examined 
with  the  sigmoidoscope,  and  probabty  represents  an  earlier 
or  milder  stage  of  the  disease  than  is  observed  in  the  post- 
mortem specimens.  The  surface  is  raw,  bleeding,  and  has  a 
granular  appearance  (see  Plate  IV,  Fig.  A).  Often  the  greater 
part  of  the  mucosa  is  destro^-ed  ;  in  severe  cases  the  muscular 
coat  is  exposed  in  the  base  of  the  ulcers,  while  in  some  the 
floor  of  the  ulcer  is  formed  by  peritoneum  only.  In  the  chronic 
t\-pe  there  is  usually  considerable  thickening  of  the  bowel-wall 
from  fibrous  tissue. 

If  the  ulcers  have  perforated  the  muscular  coat,  there  may  be 
some  local  peritonitis  and  adherent  lymph  on  the  outside  of  the 
bowel.  The  mesenteric  glands  may  be  enlarged,  and  this  was 
noted  in  several  of  the  recorded  cases,  though  in  many  there 
was  no  glandular  enlargement. 

There  is  nothing  distinctive  in  the  microscopical  appearances 
of  ulcerative  colitis.     Sections  of  the  wall  of  the  colon  through 


ULCERAXn'E     COLITIS 


159 


1 


Fig.  46. — Ulcerative  colitis,  showing  the  mucous  nienibrane  entirelj-  destroyed  down  to  the 
muscular  coat,  except  for  a  few  isolated,  islands  here  and  there.  (From  a  specimen  in  Charing 
Cross  Hjspitcii  Museum.) 


i6o  ULCERATIVE    COLITIS 

an  ulcerated  area  show  the  ordinary  characters  of  simple 
inflammation.  In  the  less  severe  cases  the  glands  of  Lieber- 
kiihn  are  seen  to  have  undergone  cloudy  swelling  and  to  contain 
fibrinous  material  in  their  lumen.  The  submucosa  is  usually 
much  thickened,  highly  vascular,  and  there  is  a  general  round- 
celled  infiltration.  The  muscular  coat  is  infiltrated  with 
leucocytes,  and  where  the  ulceration  is  deep  the  fibres  are 
destroyed.     The  peritoneum  is  thickened. 

Where  the  ulceration  has  extended  through  the  whole  depth 
of  the  mucosa,  the  islets  of  mucous  membrane  left  between  the 
ulcers  can  be  seen  to  have  become  thickened  and  swollen,  with 
the  result  that,  under  the  microscope,  they  present  the  appearance 
of  polypi  covered  with  mucous  membrane.  In  some  instances 
the  ulceration  can  be  seen  to  have  extended  under  the  mucous 
membrane,  leaving  it  attached   by  a  narrow  stalk. 

The  causes  of  death  in  the  cases  which  I  have  been  able  to 
collect  were  as  follows  : — 

Cases. 
Perforation  and  general  peritonitis  .  .  9 


Exhaustion 
Pyaemia 
Embolism 
Anuria 


17 
4 

2 

I 


Perforation  is  thus  a  common  cause  of  death.  In  nearly  all, 
the  ulcer  which  had  perforated  was  in  the  caecum  or  sigmoid 
flexure  ;  in  only  one  was  there  a  perforation  in  the  transverse 
colon,  and  in  that  a  large  portion  of  the  transverse  colon  had 
sloughed  right  away.  In  two  cases  there  was  more  than  one 
perforation.  In  one  a  perforation  into  the  general  peritoneal 
cavity  was  present  in  both  the  caecum  and  sigmoid  flexure,  and  in 
the  other  there  was  an  ulcer  in  the  caecum  the  size  of  a  shilling 
opening  straight  into  the  peritoneal  cavity,  and  five  or  six 
others,  also  perforating,  in  the  caecum  and  ascending  colon.  It 
is  difficult  to  see  how  more  than  one  perforation  can  occur,  but 
it  is  possible  that  some  sudden  strain  or  distention  of  the  bowel 
with  gas  caused  several  ulcers  to  give  way  at  the  same  time. 

Perforation  of  an  ulcer  may  occur  without  causing  general 
peritonitis  ;  in  several  of  the  cases  a  local  abscess  or  pericohtis 
had  resulted,  and  was  shut  off  by  adliesions  from  the  general 
peritoneal  cavity.  In  one  there  was  a  large  abscess  in  the  pelvis 
communicating  by  several  large  perforations  with  the  interior 


ULCERATIVE    COLITIS  i6i 

of  the  caecum.  In  another  there  was  a  pericoHc  abscess  in 
connection  with  the  sigmoid  flexure  due  to  an  ulcer  which  had 
perforated.  In  one  case  the  bases  of  some  of  the  ulcers  had 
become  adherent  to  neighbouring  coils  of  small  bowel,  and 
perforation  had  occurred  into  the  small  bowel.  There  was  a 
communication  between  the  ascending  colon  and  the  small 
intestine,  and  another  between  the  ascending  colon  and  the 
ileum. 

Adhesions  between  different  coils  of  bowel  or  between  the 
colon  and  the  parietal  peritoneum  are  not  uncommon,  and  once 
or  twice  it  was  found  post  mortem,  on  separating  the  adhesions, 
that  several  ulcers  had  perforated. 

Although  abscess  of  the  liver  is  a  common  complication  of 
amoebic  dysentery,  it  is  uncommon  in  other  forms  of  ulcerative 
colitis,  and  was  only  present  in  two  of  the  cases  I  have  collected. 
In  one  of  these  the  abscess  was  single,  in  the  other  there  were 
multiple  abscesses.  Neither  of  these  patients  had  ever  been 
out  of  England,  and  there  was  no  reason  to  suppose  they  had 
amoebic  dysentery.  One  would  expect  portal  pyaemia  to  be 
a  common  complication,  but  out  of  nearly  sixty  cases  it  was 
present  in  these  two  only.  In  one  other  instance  there  were 
symptoms  of  liver  abscess,  but  the  patient  recovered  without 
operation. 

Haemorrhage  serious  enough  to  threaten  life  may  result  from 
an  ulcer  opening  up  an  artery,  and  in  haemorrhagic  colitis  the 
bleeding  is  the  most  serious  symptom.  General  peritonitis 
may  result  from  ulcerative  colitis  without  any  perforation  being 
present. 

Symptoms. 

The  main  symptom  in  all  cases  is  diarrhoea ;  and  it  is 
this  which  draws  attention  to  the  disease.  It  may  begin 
suddenly,  accompanied  by  severe  abdominal  pain,  or,  rarely, 
may  come  on  insidiously  with  a  slight  looseness  of  the 
bowels.  Usually  the  patient  states  that  the  pain  and  diarrhoea 
started  quite  suddenly,  without  any  very  apparent  cause.  The 
stools  increase  in  frequency,  and  blood  appears.  The  ordinary 
remedies  as  a  rule  have  no  affect  upon  the  diarrhoea,  and  the 
patient  rapidly  loses  weight  and  becomes  extremely  ill.  The 
number  of  stools  varies  considerably.  A  common  number 
is  six  to  eight,  and  I  have  seen  several  instances  where  there 

II 


i62  ULCERATIVE    COLITIS 

were  twentV;  in  the  t\vent3^-four  hours.  The  stools  are  quite 
\vater\-,  and  contain  comparativeh" little  faecal  material,  consisting 
mostly  of  mucus,  blood,  pus,  water,  and  undigested  food.  In 
a  severe  case  of  ulcerative  colitis  the  food  passes  through  the 
alimentax}-  tract  with  surprising  rapiditj-.  If  charcoal  is  given 
with  the  food,  we  can  easih'  ascertain  how  long  any  particular 
feed  has  taken  in  traversing  the  ahmentar\'  canal,  as  the 
excreta  will  be  coloured  black.  If  this  test  is  apphed,  it  will 
be  found  that  a  feed  wiU  sometimes  appear  in  the  stools  in  as 
short  a  time  as  three  hours.  It  is  not  surprising,  therefore, 
that  in  bad  cases  we  sometimes  see  milk  in  the  stools  almost  in 
the  condition  in  which  it  was  swallowed.  In  the  worst  cases 
the  patient  is  practicalh-  unable  to  digest  an3'thing,  and  wasting 
and  loss  of  weight  are  in  consequence  rapid  and  severe. 

The  amount  of  blood  in  the  stools  varies  ;  in  some  cases  it  is 
considerable,  while  in-  others  it  is  onlv  present  occasionally 
in  small  quantities.  It  is  usually  fluid,  and  intimately  mixed 
with  the  stool :  it  ma}^  however,  appear  as  small,  jelly-hke  clots. 

The  desire  to  go  to  stool  is  sudden  and  urgent,  but  defaecation 
is  not  as  a  rule  accompanied  bj-  tenesmus.  Personally  I  have 
never  seen  a  patient  with  ulcerative  cohtis  in  whom  there  was 
well-marked  tenesmus,  and  although  some  writers  give  it  as 
a  common  s\-mptom,  I  beHeve  it  to  be  exceptional.  When 
present,  it  points  to  severe  ulceration  in  the  rectum.  In  acute 
tropical  d3'sentery,  however,  tenesmus  is  a  common  s\-mptom. 

There  is  not  infrequently  considerable  abdominal  pain  and 
tenderness.  The  pain  is  referred  to  the  abdominal  wall,  but 
is  not  weU  locaUzed.  The  tenderness  is  most  marked  in  the 
left  iliac  fossa  and  in  the  left  loin,  but  often  extends  over  the 
whole  colon. 

The  character  of  the  stools  \'arie5  considerabh-,  but  they  are 
always  thin,  water\-,  and  contain  blood.  Pus  is  seldom  present 
in  an\-  large  amount,  but  can  always  be  detected  on  microscopical 
examination.  There  is  always  mucus,  and  often  sloughs  can  be 
seen  if  the  stools  are  carefull}'  examined.  They  are  usually 
ver\'  foetid.  The  digestion  is  much  disturbed,  and  nausea  and 
vomiting  ma\-  occur  and  cause  considerable  distress.  Vomiting 
is,  however,  exceptional,  except  in  the  more  acute  cases,  and, 
indeed,  many  patients  suffering  from  chronic  ulcerati^'e  colitis 
have  surprisingly  few  sjmiptoms  apart  from  the  diarrhoea  and 
consequent  loss  of  weight.     I  have  even  seen  patients  with  the 


ULCERATIVE    COLITIS  163 

pelvic  colon,  showing  extensive  and  severe  ulceration,  who  were 
able  to  get  about  and  who  complained  only  of  the  constant 
diarrhoea. 

The  progress  of  the  disease  varies  a  good  deal.  Some  patients 
get  rapidly  worse,  go  steadily  downhill  from  the  first,  lose  much 
weight,  seem  unable  to  digest  anything,  and  in  a  few  weeks 
become  wasted  skeletons.  Others  seem  to  go  on  for  months, 
sometimes  a  little  better,  and  sometimes  worse.  Others  again, 
after  a  severe  attack  lasting  several  weeks  or  months,  get  better 
and  remain  well  for  a  time,  only  to  have  renewed  attacks  which, 
as  a  rule,  are  more  severe. 

The  condition  usually  described  is  that  in  which  the  s\Tnptoms 
soon  become  serious,  and  the  patient's  life  is  threatened  ;  but 
it  is  important  to  recognize  that  there  are  other  types  of  chronic 
ulcerative  colitis  in  which  the  symptoms  are  never  very  severe, 
and  the  patient  is  able  to  get  about,  though  frequently  troubled 
with  diarrhoea.  It  has  been  stated  that  where  the  symptoms 
are  comparatively  mild  the  condition  is  not  ulcerative  colitis  ; 
but  frequent  examinations  with  the  sigmoidoscope  have 
convinced  me  that  very  extensive  ulceration  may  and  often 
does  exist,  though  it  seems  probable  that  the  ulceration  is 
confined  to  the  pelvic  colon. 

The  temperature  is  commonly,  though  not  invariably,  raised. 
Except  in  the  more  severe  cases  it  is  not  high,  but  varies  between 
100''  F.  and  101°  F.  The  chart,  if  examined,  usually  shows  a  very 
irregular  temperature  of  the  type  we  generally  associate  with 
chronic  septic  poisoning.  I  have  seen  several  cases,  however,  in 
which,  although  there  was  severe  diarrhoea  and  ihe  sigmoidoscope 
showed  extensive  ulceration,  the  temperature  never  rose  over 
99°  F.  while  the  patient  was  under  observation.  These  were, 
however,  all  very  chronic  cases,  in  which  the  symptoms  had 
existed  for  months  or  years.  xA-ll  observers  agree  that  relapses 
are  very  common  in  those  cases  which  are  not  fatal.  When 
death  occurs  it  is  usually  due  to  exhaustion  and  wasting  ;  less 
frequently  to  perforation  and  general  peritonitis  ;  and  in  a 
few  instances  to  haemorrhage.  At  the  present  day  the  diagnosis 
should  not  be  difficult,  as  the  pelvic  colon  is  always  involved, 
and  this  can  be  directly  examined  with  the  sigmoidoscope. 
The  instrument  must,  however,  be  used  with  great  care,  because 
the  bowel  wall  is  weak  and  friable.  In  experienced  hands  there 
is   no   risk   in   using   the   sigmoidoscope  ;    but   no   one   who   is 


i64  ULCERATIVE     COLITIS 

unaccustomed  to  the  instrument  should  attempt  an  examination 
in  suspected  ulcerative  colitis.      {Plate  IV,  Fig.  A.) 

The  disease  can,  as  a  rule,  be  diagnosed  from  the  symptoms  ; 
but  unless  the  sigmoidoscope  is  employed  there  are  several 
conditions  with  which  it  can  easily  be  confused.  The  most 
important  of  these  is  cancer  of  the  pelvic  colon  or  upper  end 
of  the  rectum,  which  not  infrequently  gives  rise  to  identical 
symptoms.  Another  is  a  high-lying  fibrous  stricture  with 
secondary  ulceration  in  the  bowel  above.  The  condition  may 
also  be  confused  with  enteric  fever,  and  with  acute  proctitis. 

Acute  tropical  amoebic  dysentery  is  not  met  with  in  this 
country,  and  its  sjnnptoms  and  treatment  are  so  well  described 
in  modern  works  on  tropical  medicine,  that  it  will  not  be  discussed 
here.  Cases  of  chronic  dysentery  are,  however,  not  infrequently 
seen  ;  but  they  differ  in  no  important  particular,  either  as 
regards  symptoms  or  treatment,  from  chronic  ulcerative  colitis, 
except  that  when  amoebae  can  be  demonstrated  in  the  stools 
improvement  often  follows  a  course  of  special  treatment  by 
ipecacuanha. 

Natural  Healing  of  Ulcers  in  the  Colon. — It  is  difficult 
to  find  any  signs  of  repair  in  the  specimens  of  ulcerative  colitis 
beyond  some  thickening  of  the  bowel-wall  and  a  little  adherent 
lymph  on  the  peritoneum.  Occasionally  pigmented  spots  are 
seen  in  the  colon  which  have  been  supposed  to  be  the  remains 
of  old  ulcers.  One  would  expect  that  when  an  ulcer  of  the  colon 
of  any  size  healed,  a  considerable  scar  would  be  left  and  there 
would  be  a  tendency  to  contraction  and  stricture.  This  appears, 
however,  to  be  very  rare.  In  the  formation  of  scars  the  mucous 
lining  of  the  bowel  appears  to  behave  very  differently  from  the 
skin.  We  know  that  quite  large  ulcers  in  the  small  intestine 
due  to  enteric  fever  will  heal  and  leave  practically  no  scar,  and 
certainly  no  stricture  or  contraction  of  the  bowel-wall.  And 
it  is  a  very  striking  fact  that  if  the  interior  of  the  bowel  is 
examined  some  year  or  more  after  an  operation,  such,  for  instance, 
as  an  anastomosis,  has  been  performed,  the  scar  is  often  almost 
undetectable.  I  have  on  several  occasions  examined  the  interior 
of  the  sigmoid  flexure  with  the  sigmoidoscope  after  a  portion 
has  been  resected,  and  been  almost  unable  to  find  the  line  of 
union,  so  slight  was  the  scar. 

In  a  number  of  cases  of  ulceration  of  the  colon  I  have  been 
able  with  the  sigmoidoscope  to  watch  from  time  to  time  the 


ULCERATIVE    COLITIS  165 

process  of  repair  in  ulcers  which  could  be  seen  in  the  sigmoid 
flexure.  These  ulcers  can  be  seen  gradually  to  diminish  in  size 
until  only  a  slight  white  mark  is  left,  and  if  examined  a  little 
later,  even  this  has  disappeared,  leaving  no  perceptible  scar. 
I  have  seen  ulcers  as  large  as  a  sixpence  which  looked  quite 
deep,  and  which  apparently  exposed  or  even  involved  the 
muscular  coat,  disappear  without  leaving  any  obvious  scar. 
Apparently  it  is  only  when  the  ulceration  is  very  deep,  in\'olving 
the  muscular  coat,  and  also  very  extensive,  that  any  appreciable 
scar  results. 

I  have  onh^  twice  been  able  with  certaintv  to  trace  a  stricture 
of  the  colon  to  a  previous  ulceration.  But  though  this  is  very 
uncommon,  there  are  several  specimens  in  museums  of  fibrous 
stricture  in  the  colon,  in  which  it  seems  almost  certain  that  the 
stricture  is  due  to  ulcerative  colitis.  It  is  not  uncommon  to 
see  a  tight  fibrous  stricture  occur  in  the  rectum  as  the  result  of 
extensive  ulceration,  and  the  same  thing  doubtless  occasionally 
occurs  in  the  colon.  It  seems  probable  that  most  cases  of 
ulcerative  colitis  in  which  the  ulceration  is  sufficiently  severe 
to  cause  contraction,  die  from  the  initial  disease.  On  one 
occasion  I  examined  with  the  sigmoidoscope  a  woman  who 
gave  a  history  of  previous  bowel  trouble  which  suggested  ulcera- 
tion in  the  pelvic  colon,  and  I  was  able  to  see  a  narrow  ring 
stricture  in  the  middle  of  the  sigmoid  flexure,  evidently  of  a 
fibrous  nature,  and  which  appeared  probablv  to  have  resulted 
from  the  contraction  of  a  healed  ulcer.  A  case  is  reported  by 
Dr.  Tooth,  of  a  woman  who  died  from  chronic  ulcerative  colitis 
in  St.  Bartholomew' 's  Hospital ;  the  colon  was  extensively 
ulcerated,  and  there  was  a  contraction  of  the  bowel  at  the 
splenic  flexure. 

Ouenu  records  a  death  from  intestinal  obstruction  due  to  a 
simple  ulcer  at  the  lower  end  of  the  sigmoid,  which  had  con- 
tracted and  caused  a  stricture. 

Prognosis. 

The  prognosis  is  distinctly  bad  unless  an  operation  is  per- 
formed. A  majorit}'  of  the  cases  die,  and  the  mortality  is  very 
high.  The  more  extensive  use  of  the  sigmoidoscope,  however, 
has  proved  that  many  recover,  and  that  the  condition  is  not 
so  fatal  as  was  previously  supposed  when  a  post-mortem 
examination  was  the  onlv  certain  means  of  dia.mosis. 


i66  ULCERATIVE     COLITIS 

With  non-operative  treatment,  recovery,  even  if  it  occurs,, 
is  very  slow,  and  recurrence  in  a  few  months  extremely  common. 
In  the  more  acute  cases,  the  prognosis  is  so  grave  that  no  time 
should  be  wasted  in  a  prehminary  trial  of  non-operative  measures, 
but  operation  should  be  performed  at  once  before  the  patient 
has  become  seriously  weakened  by  the  disease.  Out  of  80 
cases  which  were  admitted  to  St.  Thomas's  Hospital  between 
the  years  1883  and  1907,  50  per  cent  died,  and  the  condition 
of  the  remainder  was  as  follows  : — 

No  improvement  .  .  .  .  .  .  14 

Improved,  but  symptoms  persisting  .  .  .  .  19 

Cure  or  great  improvement  .  .  .  .  7 

Thus  onty  7  cases  out  of  80  showed  any  marked  improvement 
as  the  result  of  treatment,  and  of  these  7,  5  were  apparentlj'- 
treated  by  operation. 

Follicular  Ulceration. —  This  is  generally  considered  a 
distinct  form  of  ulcerative  colitis.  The  ulcers  are  small  and 
discrete.  They  start  by  swelling  and  inflammation  of  the  solitary 
follicles  of  the  mucosa  ;  the  central  portion  then  sloughs  and 
leaves  a  small  crater-like  ulcer  wdth  a  bright  red  areola.  The 
ulcers  do  not  extend  deeply ;  they  are  circular  in  outline,  with 
well-marked  edges.  They  are  always  multiple.  They  maj'- 
enlarge  to  about  the  size  of  a  pea,  but  are  seldom  larger  than 
this,  and  are  never  confluent  ;  but  it  is  by  no  means  certain 
that  the  more  extensive  ulcers  do  not  sometimes  originate  in 
follicular  ulceration.  I  have  not  found  any  case  in  which  this 
form  of  ulceration  has  caused  perforation.  (See  Plate  IV, 
Fig.  B.) 

This  form  of  ulcerative  coHtis  occurs  as  a  complication  of 
other  diseases.  It  is  chiefly  of  interest  here  because  it  occurs 
in  association  with  cancer  of  the  alimentary  canal.  I  have 
found  it  so  associated  in  three  cases.  In  one  there  was  cancer 
of  the  stomach  and  follicular  ulceration  of  the  whole  colon. 
In  one  there  were  numerous  follicular  ulcers  helow  a  cancerous 
stricture  of  the  sigmoid ;  and  in  the  third  case  there  was 
epithelioma  of  the  anus. 

Symptoms  and  Prognosis. — The  S3^mptoms  are  the  same 
as  in  other  forms  of  chronic  ulcerative  colitis,  but  are  much  less 
severe  when  the  condition  occurs  in  adults.  It  is  a  not  uncommon 
form  of   acute  colitis  in  children,    and  manv  of  the    summer 


ULCERATIVE    COLITIS  167 

diarrhoeas  which   yearly  account    for  so  ^  much   of    the   infant 
mortaht):  in  the  east  end  of  London  are  of  this  nature. 

Haemorrhagic  Colitis. — I  have  included  this  condition  in 
the  chapter  on  ulcerative  colitis  because  it  most  conveniently 
comes  under  that  heading,  though  strictly  speaking  there  is 
not  always  any  definite  ulceration.  It  is  a  very  rare  form  of 
colitis,  and  at  present  very  little  is  known  about  it.  It  is  an 
extremely  serious  and  often  fatal  disease,  and  there  are  not 
sufficient  cases  at  present  available  to  enable  us  to  draw  any 
reliable  conclusions  as  to  its  etiology.  It  appears  to  be  a  form 
of  so-called  bacillary  dysentery,  as  everything  points  to  a 
microbic  infection  as  the  cause.  It  occurs  in  young  adults, 
and  arises  suddenly  without  any  apparent  cause.  The  character- 
istic symptoms  are  profuse  and  continuous  haemorrhage  from 
the  bowel,  and  uncontrollable  diarrhoea.  It  closely  resembles 
ulcerative  colitis  and,  like  that  disease,  often  starts  suddenly 
with  abdominal  pain.  There  is  profuse  diarrhoea,  and  I  have 
seen  cases  in  which  there  were  as  many  as  twenty-five  stools 
in  the  twenty- four  hours.  The  amount  of  blood  lost  in  the 
twenty-four  hours  ma}^  be  very  considerable,  with  the  result 
that  the  patient  rapidly  becomes  dangerously  anaemic.  All 
food  passes  almost  straight  through  the  intestine  without  being 
digested,  and  in  a  very  short  time  the  patient  is  reduced  to 
an  extreme  condition  of  emaciation.  The  pulse  is  rapid  and 
almost  imperceptible,  the  temperature  is  raised,  and  the  condition 
of  the  patient  resembles  that  seen  in  a  severe  attack  of  typhoid 
fever  during  the  third  week  of  that  illness.  In  one  of  my  cases 
there  was  hjrperpyrexia,  the  temperature  going  up  to  109°  F. 
on  one  occasion.  The  stools  are  liquid  and  extremely  foul 
smelling.  The  blood  is  intimately  mixed  with  them,  and  is 
present  in  such  quantities  that  they  are  bright  red  in  colour, 
often  appearing  to  consist  of  little  else  but  blood. 

Diagnosis  and  Symptoms. — The  diagnosis  can  only  be  made 
with  certainty  by  means  of  the  sigmoidoscope.  The  appearance 
of  the  mucous  membrane  is  characteristic,  the  whole  surface 
being  dark  red  and  having  a  spongy  appearance.  Blood  can 
be  usually  seen  oozing  from  it  everywhere.  Definite  ulcers 
may  or  may  not  be  present,  and  this  will  depend  to  some 
extent  on  what  is  the  stage  of  the  disease  at  the  time  of 
examination. 


i68  ULCERATIVE    COLITIS 

The  condition  somewhat  closely  resembles  enteric  fever  in 
S5^mptomatolog3^  and  without  a  sigmoidoscopic  examination 
might  be  mistaken  for  it.  XMdal's  reaction  is,  however,  not 
obtainable,  and  there  are  no  spots  ;  moreover,  haemorrhage  is 
present  from  the  beginning.  I  have  no  doubt,  howe^'er,  that 
many  cases  hsive  been  mistaken  for  tjrphoid  fever. 

The  inflammation  is  not  confined  to  the  mucous  membrane, 
but  involves  all  the  bowel-coats,  and  the  peritoneum  covering 
the  bowel  shows  commencing  peritonitis.  The  following  is  a 
good  instance  of  this  rare  condition  : — 

The  patient  was  a  lady,  aged  30.  She  was  suddenh'  seized 
with  severe  abdominal  pain,  followed  by  diarrhoea.  The  stools 
contained  blood  and  were  very  offensive.  She  continued  to 
get  about,  but  the  diarrhoea  increased,  and  at  the  end  of  a  week 
she  was  having  as  many  as  fourteen  stools  daily,  all  of  which 
contained  blood.  There  was  no  further  pain  or  other  s;ymptom 
except  progressive  weakness  and  emaciation.  She  came  up 
to  London  and  saw  her  doctor,  who  immediately  sent  her  to 
bed  and  put  her  on  a  light  diet.  The  bleeding,  however, 
continued  in  spite  of  treatment,  and  she  had  a  temperature 
ranging  between  101°  and  102°.  I  was  asked  to  see  her  on  the 
fifteenth  daj^  after  the  onset,  and  a  sigmoidoscopic  examination 
showed  the  mucosa  of  the  pelvic  colon  to  be  spongj',  bleeding, 
and  of  a  dark-red  colour.  Hemorrhagic  colitis  was  diagnosed, 
and  it  was  decided  to  perform  appendicostomy  in  the  hope  of 
controlling  the  bleeding,  which  was  already  most  serious.  The 
operation  was  performed  at  once,  and  a  large  quantity  of 
very  foul  material  was  washed  out  of  the  colon.  The  next  day 
the  patient's  temperature,  which  had  come  down  as  the  result 
of  the  operation,  went  up  within  an  hour  and  a  half  to  109°, 
and  was  onl}'  got  down  again  b}^  continuous  sponging  and  the 
application  of  ice,  iced  water  being  also  run  into  the  colon. 
For  the  next  two  days  there  were  repeated  attacks  of  hj-'per- 
pyrexia,  and  on  two  occasions  the  temperature  reached  107° 
before  it  could  be  checked.  The  bleeding  from  the  colon  was 
stopped  in  twent3^-four  houi-s  as  the  result  of  frequent  irrigation 
of  the  colon  with  water  and  i  per  cent  arg^-rol.  A  specimen 
of  the  stools,  which  was  examined  bacteriologically,  showed 
large  numbers  of  pneumococci,  which  were  also  successfully 
cultivated,  and  the  condition  appeared  to  have  been  due  to  a 
primar}.'  infection  of  the  colon  b^-  this  organism.     There  were 


ULCERATIVE    COLITIS  169 

no  symptoms  of  lung  tz-ouble.  At  the  operation  the  caecum, 
which  was  the  only  part  of  the  large  bowel  examined,  was  found 
to  be  acutely  inflamed,  the  wall  was  considerably  thickened, 
and  there  was  much  adherent  lymph  on  the  peritoneal  surface. 
As  a  result  of  frequent  irrigation  the  colitis  got  better,  and 
the  stools  became  almost  normal  in  appearance  and  free  from 
blood.  The  temperature  came  down,  and  the  patient  seemed 
to  be  well  on  the  way  to  recovery,  when  she  died  suddenly 
from  heart  failure.* 

Treatment. — The  best  treatment  in  these  cases,  in  fact  the 
only  treatment  which  seems  to  control  the  haemorrhage,  is  to 
perform  appendicostomy  and  keep  the  colon  washed  out.  This 
rapidly  controls  the  bleeding  and  at  the  same  time  w^ashes  away 
the  highly  toxic  material  in  the  colon,  which,  owing  to  the 
damaged  condition  of  the  bowel  w^all,  is  being  absorbed  and 
poisoning  the  patient.  The  condition  is  a  very  serious  one, 
both  on  account  of  the  great  loss  of  blood  and  also  the  severe 
degree  of  toxaemia  which  results  from  it,  and  I  am  personally 
convinced  that  no  time  should  be  wasted  in  trying  palliative 
measures,  but  appendicostomy  should  be  performed  as  soon  as 
possible  after  the  condition  has  been  diagnosed.  The  bowel 
should  be  washed  out  at  once,  and  the  washing  continued  until 
the  fluid  coming  from  the  tube  in  the  rectum  is  quite  clean. 
After  that,  the  colon  should  be  irrigated  every  three  or  four 
hours  until  the  hemorrhage  is  controlled.  Hazeline,  in  the 
proportion  of  two  drachms  to  the  pint,  may  be  added  to  the 
water  used  for  irrigation,  and  if  this  fails  to  stop  the  bleeding, 
the  bowel  may  be  washed  through  with  i  per  cent  argyrol. 

During  convalescence  the  feeding  wall  require  the  most  careful 
management,  and,  in  fact,  these  cases  call  for  everj^  resource 
of  modern  medical  knov/ledge  and  skill  if  they  are  to  be  con- 
ducted to  a  successful  issue. 

Distention  or  Stercoral  Ulcers. —  These  are  commonly 
found  above  a  stricture  of  the  colon  or  rectum.  The  most 
common  situation  is  in  the  dilated  portion  of  bowel  immediately 
above  the  stricture  ;  but  they  may  occur  in  any  part  of  the 
colon  above  the  stricture  ;  thus  the  stricture  may  be  in  the 
rectum,  and  the  ulcer  in  the  caecum.     They  are  usually  multiple, 

*  Proc.  Roy.  Soc.  Med.,  vol.  iii.,  No.  2,  Clin.  Se^t.,  p.  48. 


170  ULCERATIVE    COLITIS 

discrete  ulcers  with  well-marked  edges.  They  do  not  differ  in 
any  important  particular  as  regards  their  morbid  appearance 
from  the  form  of  ulceration  already  described.  They  apparently 
arise  as  the  result  of  the  local  irritation  and  inflammation  caused 
by  retained  faecal  material  above  the  stricture.  In  fact,  they 
may  be  said  to  be  traumatic  in  origin.  They  are  seen  in  cases 
of  faecal  impaction  when  there  is  no  stricture,  and  may  occur  as 
the  result  of  chronic  constipation  alone.  I  have  seen  one  such 
case  in  which  several  stercoral  ulcers  were  present  in  the  sigmoid 
flexure  (see  Fig.  44)  of  an  old  woman  who  for  years  had 
suffered  from  chronic  constipation.  They  are  for  the  most  part 
quite  shallow,  and  involve  only  the  mucous  membrane  ;  but 
when  they  occur  above  a  stricture  they  may  in  time  expose 
the  peritoneum,  and  perforate  or  give  rise  to  local  abscess 
formation. 

Simple  Perforating  Ulcer  of  the  Colon. — There  are  a  few 
rare  cases  in  which  a  patient  has  developed  acute  general 
peritonitis,  and  either  at  the  time  of  operation  or  post  mortem 
a  single  simple  ulcer  in  the  colon  has  been  discovered  which  had 
perforated  into  the  peritoneal  cavity. 

These  cases  do  not  appear  to  belong  to  the  same  class  as 
those  of  ulcerative  colitis  which  have  previously  been  described, 
and  I  have  therefore  placed  them  separately,  though  it  may 
subsequently  transpire  that  they  should  not  be  so  divided. 

They  bear  a  close  resemblance  to  perforating  duodenal  and 
gastric  ulcers.  They  are  distinguished  from  ordinary  ulcerative 
colitis  in  that  there  is  only  a  single  ulcer,  or  at  most  two,  the 
remainder  of  the  colon  being  healthy,  and  that  there  are  none 
of  the  usual  sjnnptoms  of  ulcerative  colitis  ;  in  fact,  in  many 
there  do  not  appear  to  have  been  any  definite  symptoms  until 
the  sudden  onset  of  general  peritonitis. 

In  one  case  the  patient,  a  man  who  was  not  known  to  have 
suffered  from  any  bowel  trouble,  was  operated  upon  for  a  stone 
in  the  bladder  ;  he  died  three  days  after  the  operation,  and  post 
mortem  there  was  found  general  peritonitis  due  to  a  simple, 
ulcer  in  the  splenic  angle  of  the  colon  which  had  perforated. 

In  a  case  of  Ouenu's,  the  patient,  who  was  suffering  from 
acute  pneumonia,  developed  acute  abdominal  pain  on  the 
fourteenth  day  of  the  illness,  and  died  with  symptoms  of 
general   peritonitis.     Post  mortem  there    was  a  single  ulcer  in 


ULCERATIVE    COLITIS  171 

the  descending  colon  which  had  perforated,  and  also  an  ulcer 
in  the  stomach.  In  several  there  was  a  stricture  or  obstruction 
in  the  colon  below  the  situation  of  the  ulcer.  In  one,  a 
volvulus  of  the  sigmoid  flexure  had  been  operated  upon  and 
untwisted  three  da3.'s  before  an  ulcer  in  the  caecum  perforated. 

In  another  case  reported  by  Ouenu,  the  patient  died  after 
an  illness  lasting  seventeen  days,  with  symptoms  of  perforation 
and  peritonitis.  Post  mortem  there  was  a  single  ulcer  about 
one  inch  in  diameter  in  the  transverse  colon,  which  had  per- 
forated ;  there  was  also  an  ulcer  in  the  stomach.  In  one  case 
there  was  a  simple  ulcer  the  size  of  a  shilling  in  the  sigmoid 
flexure,  which  had  perforated  and  caused  an  abscess  ;  the  patient 
died  from  pyemia. 

I  have  been  able  to  find  records  of  eighteen  such  cases  in 
which  there  was  either  a  single  ulcer  in  the  colon,  or  two  small 
ulcers  close  together,  the  remainder  of  the  colon  being  quite  free 
from  ulceration.  All  but  two  were  men,  and  their  ages  varied 
between  27  and  67. 

The  situation  of  the  ulcer  is  shown  in  the  following  table  : — 


Sigmoid  flexure 

Ascending  colon  or  hepatic  flexure 

Descending  colon  or  splenic  flexure 

Transverse  colon 

Csecum 


Cases 

7 
4 

5 
I 
2 


In  three  cases  an  obstruction  existed  below  the  ulcer.  In 
one  the  ulcer  w^as  tuberculous,  and  one  was  due  to  typhoid 
fever.  One  patient  was  suffering  from  acute  pneumonia  ;  but 
there  is  not  positive  evidence  that  the  ulcer  was  caused  by  the 
pneumococcus.  In  the  remaining  cases  there  was  present  no 
apparent  cause  for  the  ulcer,  and  no  other  lesion  of  the  colon. 
In  most  there  was  a  history  of  constipation,  but  otherwise  no 
trace  of  any  bowel  trouble  until  the  sudden  onset  of  symptoms 
of  perforation.  In  one  or  two  there  was  a  history  of  localized 
pain  and  tenderness  in  the  abdomen  over  the  situation  of  the 
ulcer  for  a  few  weeks. 

In  one  case  two  small  concretions  were  found  outside  the 
bowel  which  had  evidenth^  come  through  the  perforation.  The 
ulcer  had  perforated  the  bowel  wall  in  all  but  one  of  the  cases, 
and  had  caused  either  an  abscess  or  general  peritonitis. 

In  a  case  reported  by  Dr.  Bradbury,  there  was  no  apparent 


172  ULCERATIVE    COLITIS 

perforation.  The  patient  was  a  man,  aged  30,  who  died  after 
an  illness  which  commenced  with  sudden  pain  in  the  abdomen. 
Post  mortem  there  was  a  single  small  ulcer  of  the  caecum,  which 
had  not  perforated.  The  appendix  and  the  rest  of  the  colon 
and  small  bowel  were  quite  health}^  There  were  multiple 
abscesses  of  the  liver  and  a  right-sided  empyema. 

In  tw^o  of  the  cases  there  was  an  ulcer  in  the  stomach  in  addition 
to  that  in  the  colon.  This  is  particularly  interesting  in  view 
of  the  close  resemblance  which  these  ulcers  of  the  colon  bear  to 
gastric  ulcers.  In  three  the  lesion  was  undoubtedly  a  distention 
or  stercoral  ulcer  occurring  abo\'e  a  stricture  or  obstruction, 
and  it  seems  possible  that  in  many  of  the  others  the  ulcer  was 
of  a  traumatic  nature,  and  caused  b}-^  the  retention  for  long 
periods  of  hardened  faecal  masses. 

In  addition  to  the  forms  of  perforating  ulcer  of  the  colon 
already  mentioned,  there  are  two  others  of  importance.  Typhoid 
ulcer aiion  of  the  colon  is  not  common,  but  I  have  been  able  to 
collect  seven  cases  in  which  a  typhoid  ulcer  of  the  colon  per- 
forated and  caused  fatal  peritonitis.  In  one  case  the  ulcer  was 
in  the  ascending  colon,  in  two  in  the  hepatic  flexure,  in  two 
in  the  caecum,  and  in  two  in  the  sigmoid  flexure.  Tuberculous 
ulceration  of  the  colon  ma\'  also  result  in  perforation. 

Treatment    of    Ulcerative    Colitis. 

Chronic  ulcerative  colitis  is  a  disease  about  which,  until 
quite  recently,  but  little  was  known,  and  about  which  there  is 
still  much  to  learn.  The  cases  have  either  had  no  special  treat- 
ment or  have  been  treated  b}^  restricted  and  special  dietary, 
combined  with  attempts  to  wash  out  the  lower  bowel  with 
antiseptic  or  silver  solutions. 

The  cases  treated  by  careful  nursing  and  dietar3/-,  or  by  the 
administration  of  drugs,  almost  invariabh'  died,  and  the  only 
medical — as  opposed  to  surgical — treatment  which  has  been  at 
all  successful  has  been  that  in  which  an  attempt  has  been  made 
to  wash  out  the  bowel  with  weak  solutions  of  antiseptics  ;  though 
it  cannot  be  said  that  even  this  has  met  with  much  success. 

Dr.  Hale  White,  in  the  discussion  which  took  place  at  the 
Ro3'al  Society  of  Medicine  on  ulcerative  colitis,  stated  that  he 
knew  of  three  cases  which  had  apparently  recovered  as  the  result 
of  treatment  by  coli  vaccine. 

Apparently   the    first    instance    of   chronic   ulcerative    colitis 


ULCERATIVE    COLITIS  173 

treated  by  operation  was  a  case  of  Hahn's,  in  1880.  The 
patient  was  a  prostitute,  and  it  was  at  first  supposed  that  the 
ulceration  was  due  to  syphihs,  but  as  it  did  not  improve  under 
antisyphiHtic  treatment,  he  performed  colotomy.  Previous  to 
operation  she  was  very  ill,  and  had  lost  68  lbs.  in  weight,  but 
she  made  a  complete  recovery.  As  the  result  of  an  attempt  to 
close  the  artificial  anus  two  years  later,  she  died  of  pyaemia. 

The  first  successful  caecostomy  for  ulcerative  colitis  seems  to 
have  been  performed  in  Italy,  in  1887,  by  Novara. 

Of  the  60  cases  which  I  have  been  able  to  collect,  33  were 
treated  medically  and  27  by  operation. 

Of  the  cases  not  operated  upon,  26  died  and  only  seven 
recovered,  while  of  those  operated  upon,  21  recovered,  and 
only  six  died. 


Died. 

RECOVEKBO.    j     ™--- 

Cases  not  operated 

upon                 .  .    33 
Cases  operated  upon  27 

26 
6 

7 
21 

78 
22 

Total         60 

32 

28 

These  figures  are  striking  enough,  but  we  have  also  to  take 
into  consideration  the  fact  that  operation  has  hitherto  been 
reserved  as  a  rule  for  the  worst  cases,  and  often  after  other  forms 
of  treatment  have  failed.  There  is  thus  every  reason  to  hope 
that  when  the  value  of  operation  is  better  known,  the  great 
majority  of  the  patients  will  recover,  and  instead  of  recovery 
being  the  exception,  it  will  become  the  rule. 

There  are  two  methods  of  treatment  by  operation  : — (i) 
Giving  rest  to  the  colon  by  establishing  an  artificial  amis  ;  (2) 
Making  an  opening  through  which  the  colon  can  be  irrigated  and 
the  u  cerated  areas  kept  clean, 

Two  other  methods  suggest  themselves,  namely,  to  short- 
circuit  the  colon  by  ileo-sigmoidostomy,  and  to  excise  the 
diseased  colon.  Neither  of  these  is,  however,  possible  except 
in  most  exceptional  cases.  The  rectum  and  sigmoid  are  generally 
the  parts  of  the  bowel  in  which  there  is  most  ulceration,  and 
therefore  the  anastomosis  would  have  to  be  done  with  diseased 
bowel.     For  the   same   reason   excision  would  not  be  possible 


174  ULCERATIVE     COLITIS 

even    if    the  patients  were  not  too  ill   to    stand  so  severe  an 
operation. 

1.  Giving  Rest  to  the  Colon. — As  the  pathology  of  ulcerative 
colitis  clearly  shows  that  the  ulceration  usually  extends  through- 
out the  whole  of  the  colon,  it  is  obvious  that  the  artificial  anus 
should  be  made  in  the  csecum  if  the  operation  is  to  be  successful. 
This  is  also  clearly  shown  by  the  results  of  operation,  as  out  of 
six  cases  treated  by  colostomy  on  the  left  side,  three  died,  while 
the  six  cases  treated  by  csecostomy  all  recovered. 

Where  right-sided  colostomy  or  csecostomy  has  been  performed, 
the  results  have  been  good  as  regards  a  cure  of  the  ulceration. 
The  symptoms  ha\'e  subsided,  and  the  patient  has  rapidly 
improved  in  health.  The  operation  is,  however,  objectionable, 
as  a  right-sided  colostomy  is  even  more  unpleasant  than  a  left- 
sided  colostomy.  Moreover,  it  is  frequently  impossible  or  inad- 
visable to  close  the  opening,  and  it  has  to  be  retained  as  a 
permanent  outlet  for  the  fseces.  In  several  cases  an  attempt 
to  close  the  opening  has  immediately  resulted  in  a  recurrence 
of  the  symptoms  of  ulceration,  and  in  a  few,  fatal  peritonitis 
has  resulted  from  the  attempt.  Mr.  Makins,*  who  has  performed 
the  operation  in  six  cases,  has  given  it  as  his  opinion  that  if  the 
opening  cannot  be  closed  in  eight  or  nine  months,  it  will  sub- 
sequently become  impossible  to  close  it  on  account  of  the 
contraction  which  occurs  in  the  disused  colon,  and  that  if  a 
right-sided  colostomy  is  performed  in  these  cases  the  patient 
must  be  prepared  for  the  probability  that  the  opening  will  be 
a  permanent  one. 

Therefore,  as  regards  curing  the  patient,  a  right-sided  colostomy 
may  be  expected  to  give  good  results  ;  but  it  will  not  infrequently 
be  at  the  expense  of  leaving  the  patient  with  a  permanent 
artificial  anus.  A  right-sided  lumbar  colostomy  is  preferable  to 
a  csecostomy  on  account  of  the  more  solid  nature  of  the  stools, 
and  appears  to  give  as  good  results  as  a  csecostomy. 

2.  Operation  for  Establishing  a  Means  of  Irrigating 
THE  Colon. — The  operation  of  choice  in  cases  of  ulcerative  colitis 
is,  without  doubt,  appendicostomy,  or  if  this  is  impossible  owing 
to  the  appendix  being  diseased  or  having  already  been  removed, 
a  valvular  opening  which  will  just  admit  a  catheter  should  be 
established.     At   first   the   colon   should  be   washed  out  twice 

*  Proc.  Roy.  Soc.  of  Med.   Jan.   26,   1909,  Med.  Sect. 


ULCERATIVE    COLITIS  175 

daily  with  either  plain  water  or  normal  saline,  a  tube  being 
placed  through  the  anal  sphincters  to  allow  the  fluid  to  run  out. 
Later,  a  weak  solution  of  protargol  or  arg^Tol  may  be  used  with 
advantage. 

This  operation  gives  excellent  results  ;  the  ulceration,  as 
a  rule,  quickly  heals,  the  patient  puts  on  weight,  and  the 
diarrhcea  is  controlled. 

I  have  seen  most  excellent  results  from  this  operation  in  bad 
ulcerative  cohtis,  and  it  has  such  manifest  advantages  over 
colostomv  that  I  think  it  should  always  be  done  except,  per- 
haps, in  a  few  exceptional  cases.  It  does  not  leave  the  patient 
with  an  unpleasant  opening,  or  cause  him  the  least  discomfort 
or  inconvenience,  and  it  can  be  closed  at  any  time  without 
an  operation. 

The  following  are  instances  of  the  good  results  which  follow 
this  operation  : — 

Case. — The  patient  was  a  man,  aged  35,  who  for  nine  months 
had  been  suffering  from  almost  constant  diarrhoea.  He  was  very 
weak  and  much  wasted.  The  stools  contained  a  considerable 
quantity  of  blood.  A  sigmoidoscopic  examination  showed  numerous 
discrete  ulcers  in  the  pelvic  colon.  Appendicostomy  was  performed, 
and  the  colon  kept  washed  out  with  warm  water.  The  diarrhoea 
was  at  once  controlled,  there  was  no  further  bleeding,  and  the  patient 
made  a  rapid  recovery.  A  month  after  the  operation  he  left  the 
hospital.  He  continued  for  six  months  to  wash  the  colon  out 
daily,  but  returned  to  his  employment.  He  had  no  further  sym- 
ptoms, and  a  sigmoidoscopic  examination  six  weeks  after  operation 
showed  that  all  the  ulcers  were  healed.  A  year  and  three  months 
after  operation  he  was  quite  well  and  had  had  no  recurrence  of 
the  previous  symptoms. 

Case. — A  lady,  aged  25,  had  for  five  weeks  been  suffering 
from  constant  diarrhoea,  and  the  symptoms,  in  spite  of  all  treatment, 
had  been  getting  worse  during  the  last  month.  The  stools  contained 
large  quantities  of  blood,  she  had  become  very  anaemic,  and  wasted 
almost  to  a  skeleton.  Some  six  months  previously  she  had  had  a 
slight  similar  attack,  which  had,  however,  quickly  passed  off.  On 
the  present  occasion,  however,  she  had  become  steadily  worse,  and 
her  condition  was  very  grave.  The  sigmoidoscope  showed  extensive 
ulceration  and  a  hsemorrhagic  condition  of  the  mucous  membrane. 
Treatment  by  a  special  vaccine  failed  to  do  any  good.  Appen- 
dicostomy was  performed,  and  the  colon  was  washed  out  frequently 
with  warm  water.     As  a  result  of  this  treatment  the  haemorrhage 


176  ULCERATIVE    COLITIS 

and  diarrhoea  were  controlled  within  thirty-six  hours.  The  patient 
rapidly  improved  in  health,  and  in  two  months  was  quite  well. 
The  irrigation  was  continued  once  daily  for  the  next  two  months. 

Case,. — I  was  consulted  by  a  lady,  aged  31,  who  three  years 
ago  had  contracted  dysentery  while  resident  in  the  East.  She  had 
suffered  on  and  ofE  ever  since  from  diarrhoea  and  bleeding  from  the 
bowel.  When  I  saw  her  the  bowels  acted  six  or  seven  times  a  day, 
there  was  blood  in  the  stools,  and  she  was  often  sick.  Medical 
treatment  had  quite  failed  to  do  any  good,  and  she  was  practically 
confined  to  bed,  the  least  attempt  to  move  about  bringing  on  severe 
diarrhoea.  Appendicostomy  was  performed,  and  at  the  operation 
a  number  of  chronic  ulcers  could  be  felt  in  the  colon,  especially  in 
the  transverse  portion.  The  bowel  was  kept  washed  out,  and  in 
three  weeks  all  the  symptoms  had  disappeared.  She  became  quite 
well,  and  was  able  to  return  to'  the  East.  I  have  since  heard  from 
her,  and  there  has  been  no  return  of  the  symptoms. 

Of  the  18  cases  which  I  have  been  able  to  collect  in  which 
appendicostomy  was  performed,  17  recovered,  and  8  of  these 
remained  well  and  free  from  any  relapse.  One  died  a  year 
later  from  the  results  of  another  operation,  though  there  was  no 
return  of  the  ulceration.  One  died  three  weeks  after  the 
operation,  but  it  was  found  post  mortem  that  the  lower  part  of 
the  ileum  was  ulcerated  in  addition  to  the  colon. 

Appendicostomy  and  irrigation  of  the  colon  appears  to  be 
the  best  treatment  in  these  cases.  It  should  be  performed  as 
soon  as  possible,  and  not  as  a  last  resort. 

Treatment  of  Complications. 

Of  these  there  are  three  which  are  likely  to  call  for  surgical 
treatment  :    (i)    Perforation  ;  (2)  Hcsmorrhage  ;   (3)  Abscess. 

I.  Perforation. — ^With  very  few  exceptions  this  complication 
is  fatal,  unless  an  operation  can  be  performed  in  time  ;  and 
only  immediate  intervention  can  save  the  patient's  life. 

The  success  which  has  attended  the  treatment  by  operation 
of  perforated  gastric  ulcer,  and  perforation  of  the  appendix, 
can  certainly  be  repeated  in  dealing  with  these  cases  of  per- 
forating ulcer  of  the  colon,  once  the  condition  becomes  suffi- 
ciently well  recognized  for  an  early  diagnosis  to  be  made,  and 
providing  the  surgeon  is  able  to  operate  soon  after  the  per- 
foration has  taken  place.  Unfortunately,  up  to  the  present, 
this  has  seldom  been  the  case  ;    the  perforation  has  either  not 


ULCERATIVE    COLITIS  177 

been  diagnosed  during  life,  or  the  surgeon  has  been  called  in 
too  late  for  there  to  be  any  reasonable  chance  of  doing  good. 

A  correct  diagnosis  is  very  difficult  in  these  cases,  and  it  will 
seldom  be  possible  for  the  clinician  to  do  more  than  diagnose  a 
probable  perforation  in  some  part  of  the  intestine.  Unless  the 
surgeon  bears  in  mind  the  possibiUty  of  a  perforating  ulcer  of 
the  colon  when  he  comes  to  operate,  and  carefully  examines  the 
colon  after  having  excluded  a  perforated  appendix  or  gastric 
ulcer,  the  perforation  will  probably  be  missed.  This  occurred 
in  one  case  where  perforation  and  general  peritonitis  were 
diagnosed  and  the  abdomen  opened ;  a  slightly  inflamed 
appendix  was  removed,  but  the  cause  of  the  peritonitis,  which 
was  a  perforation  of  the  colon  at  the  hepatic  flexure,  was  missed, 
and  the  patient  died.  The  difficulty  of  finding  and  closing  the 
perforation  may  be  considerable  ;  it  may  be  in  any  portion  of 
the  colon  and  on  any  aspect.  Moreover,  there  may  be  more 
than  one  perforation  in  the  same  case. 

The  method  of  dealing  with  the  perforation  will  vary  with 
the  nature  of  the  case.  It  may  be  treated  like  a  perforation  of 
the  stomach  and  closed  by  a  purse-string  suture  reinforced  by 
a  row  of  Lembert  sutures.  In  one  case,  a  Paul's  tube  was  tied 
into  the  perforation,  which  was  in  the  caecum,  and  an  artificial 
anus  established.  The  operation  in  this  case  was  performed 
too  late,  and  the  patient  died.  Though  this  is  a  rapid  method 
of  dealing  with  the  perforation  in  cases  when  speed  is  of  the  first 
importance,  it  is  not  a  satisfactory  operation.  Another  method 
is  to  resect  the  ulcer  and  close  the  wound  in  the  bowel  in  the 
opposite  direction,  so  as  not  to  narrow  the  lumen ;  or,  if  the  ulcer 
is  large,  to  resect  a  few  inches  of  the  colon  and  unite  the  ends. 

I  have  been  able  to  collect  42  cases  of  perforation  of  the  colon 
due  to  simple  ulceration.  This  does  not  include  any  cases  of 
perforating  false  diverticula.  All  died,  with  the  exception  of 
three.  Only  six  were  operated  upon,  but  of  these,  three 
recovered.  Thus,  without  operation  the  mortality  would 
appear  to  be  100  per  cent,  and  there  is  no  doubt  that  this 
mortality  can  be  greatly  reduced  by  operation. 

Of  the  six  cases  operated  upon,  the  ulcer  was  missed  in  the 
three  that  died.  One  was  treated  by  closing  the  perforation, 
and  recovered.  In  one,  an  abscess  was  opened  and  a  faecal 
fistula  found ;  later,  the  portion  of  colon  (sigmoid  flexure) 
containing  the  ulcer  was  successfully  resected. 

12 


178  ULCERATIVE    COLITIS 

In  the  third  case  that  recovered,  the  operation  consisted  only 
of  opening  an  abscess.  In  another,  enterotomy  was  performed, 
but  the  patient  died,  and  post  mortem  a  perforating  ulcer  in 
the  sigmoid  was  discovered. 

2.  HAEMORRHAGE. — This  is  best  treated  by  washing  out  the 
bowel  with  some  suitable  astringent  such  as  hazehne  two 
drachms  to  the  pint,  complete  rest,  and  the  administration  of 
opium  (see  page  167). 

3.  Abscess. — As  soon  as  there  is  reason  to  believe  that  an 
abscess  has  formed,  an  operation  should  be  performed  and 
adequate  drainage  provided  for. 

REFERENCES. 

Hale  White. — Guy's  Hasp.  Rep.  1888. 

NoTHNAGEL. — Diseases    of    Intestines    and    Peritoneum.     English    edition 

edited  by  H.  D.  Rolleston. 
Dickinson. — Trans.  Path.  Soc.  xxxii. 
"  Discussion  on  Ulcerative  Colitis,"  Proc.  Roy.  Soc.  of  Med.  Jan.  26,  1909. 


79 


Chapter    XIII. 
PERICOLITIS. 

By  this  is  meant  a  condition  of  inflammation  around  the  colon, 
and  involving  its  walls.  In  many  respects  it  closely  resembles 
perityphHtis  or  appendicitis,  generally  differing  only  in  the 
locality  in  which  it  is  situated. 

It  is  only  of  comparatively  recent  years  that  pericolitis  has 
been  recognized  as  a  definite  form  of  disease,  though  many 
observers  had  previously  recorded  cases  of  abscess  or  inflam- 
matory tumours  in  connection  with  the  colon.  In  looking  up> 
old  records  one  not  infrequently  meets  with  cases  which  were 
obviously  of  this  nature,  but,  as  with  appendicitis  before  it 
became  a  well-recognized  condition,  little  attention  was  paid! 
to  them,  and  in  very  few  instances  were  really  careful  obser- 
vations made.  They  were  classed  as  inflammation  of  the 
bowels,  post-peritoneal  or  intra-peritoneal  abscess,  general 
peritonitis,  etc.,  without  any  distinction  being  made  as  to  the 
causation  or  pathology.  Isolated  specimens  are  to  be  found  in 
museums,  but  in  many  instances  they  are  wrongly  described 
or  classified,  and  in  not  a  few  the  specimen  is  labelled  "  Cancer 
of  the  colon." 

Lately  more  attention  has  been  paid  to  this  disease,  and 
several  carefully  observed  cases  have  been  recorded.  Even 
at  the  present  time,  however,  pericolitis  does  not  find  a  place 
in  the  ordinary  medical  text-books,  and  many  medical  men 
know  nothing  about  it,  or  look  upon  it  only  as  a  rare  pathological 
condition  of  little  interest  except  to  the  pathologist. 

Pericolitis  is  probably  not  a  rare  condition,  but  on  the  other 
hand  it  is  one  which  occurs  comparatively  often,  and  I 
believe  that,  when  its  S3nnptoms  and  pathology  are  well  known 
and  recognized,  it  will  be  found  to  be  a  by  no  means  uncommon 
disease  of  the  alimentary  tract. 

Post-mortem  statistics  would  lead  us  to  conclude  that  peri- 
colitis is  a  rare  disease.     Cases  are  very  difficult  to  find  in  the 


i8o  PERICOLITIS 

post-mortem  records  of  large  hospitals,  and  the  same  applies  to 
the  hospital  case-books.  If  classified  at  all,  it  is  under  the 
general  head  of  abscess,  and  usuallj^  the  cause  is  not  even 
suggested. 

The  great  majority  of  cases  have  ended  fatally,  and  the 
condition  has  only  been  detected  post  mortem. 

Etiology. 

Pericolitis  is  a  disease  of  advanced  life.  The  majority  of 
the  patients  are  oxev  the  age  of  forty,  the  a\'erage  of  the  cases 
I  have  been  able  to  collect  being  fifty  years.  The  youngest  I 
have  found  is  that  of  a  girl  of  eighteen.  There  are  two  others 
of  twenty-two  and  one  of  twenty-three  in  mv  series,  but  most 
are  considerably  older. 

It  is  somewhat  remarkable  that,  apart  from  tubercle,  there 
appear  to  be  no  records  of  the  condition  in  children,  although 
intestinal  complaints  are  common  enough  in  infancy.  The 
reason  why  the  disease .  is  chiefl\'  confined  to  the  later  part  of 
life  lies  probabl}^  in  the  important  part  played  by  chronic 
constipation  as  an  etiological  factor. 

The  portion  of  the  colon  most  commonly  attacked  in  peri- 
colitis is  the  sigmoid  flexure,  but  an}'  part  may  be  affected.  In 
the  great  majorit}'  of  cases  the  condition  occurs  either  in  the 
sigmoid  flexure  or  lower  part  of  the  descending  colon.  In  a 
few  the  splenic  angle  has  been  the  site  of  the  disease,  and  I  ha\'e 
been  able  to  find  two  instances  onl}-  of  the  transverse  colon 
being  affected. 

Pericolitis,  like  all  forms  of  inflammation,  may  be  either  acute 
or  chronic,  but  except  in  relation  to  the  symptoms,  such  a 
classification  is  of  little  if  an}-  value,  and  the  cases  will  therefore 
be  arranged  on  a  pathological  basis.  The  term  is  a  wide  one 
and  covers  a  number  of  pathological  conditions,  or  rather  there 
are  many  such  conditions  which  may  give  rise  to  pericolitis. 
Many  cases  have  been  described  as  pericolitis  sinistra,  peri- 
sigmoiditis, and  diverticulitis  ;  but  there  is  no  advantage  in 
using  these  names  :  the  term  pericolitis  includes  them,  and 
the  condition  does  not  differ  in  any  important  particular  when 
it  occurs  in  different  parts  of  the  colon. 

Under  the  general  heading  we  should  include  most  of  the 
cases  of  tuberculosis  of  the  colon,  and  certainly  all  those  of 
hyperplastic  tuberculosis.     Most  cases    of  cancer  of   the  colon 


PERICOLITIS  iSi 

are  also  sooner  or  later  complicated  by  a  pericolitis,  and  it  is 
necessary,  therefore,  to  include  this  form  of  the  condition.  As, 
however,  the  subjects  of  tuberculosis  of  the  colon  and  of 
cancer  are  more  conveniently  considered  elsewhere,  these  two 
conditions  will  not  be  included  here. 

It  is  obvious  that  with  the  exception  of  those  cases  in 
which  septic  infection  has  spread  to  the  bowel  wall  from 
some  source  unconnected  with  the  colon,  there  must  be 
a  lesion  of  the  wall  of  the  colon  which  allows  infecti\"e 
material  to  escape  from  the  bowel  lumen.  In  other  words, 
there  must  be  either  a  perforation  of  the  colon  or  an  infiltra- 
tion of  its  wall  by  some  infective  process  before  pericohtis 
can  occur.  In  the  order  of  their  importance  in  producing 
pericolitis,  the  causes  are  as  follows  :  (i)  Diverticula  of  the  colon  ; 
(2)  Ulceration  ;  (3)  Perforation  by  foreign  bodies  ;  (4)  Tubercle  ; 
(5)    Cancer  ;   (6)  Svphilis  ;   (7)  Traumatism. 

I.  Diverticula  of  the  Colon. — Bv  far  the  most  important 
cause  of  pericolitis  is  the  formation  of  acquired  diverticula. 

Since  attention  was  first  attracted  to  the  presence  of  these 
diverticula  they  have  been  a  source  of  much  interest  to  surgeons 
and  pathologists,  and  it  is  now  becoming  evident  that  the}^  are 
by  no  means  as  rare  as  was  at  first  supposed. 

They  consist  of  small  pouches  or  hernial  protrusions  of  the 
colon,  somewhat  resembling  the  pouches  seen  in  the  bladders  of 
old  men  who  have  had  obstructive  urinary  trouble. 

They  vary  in  size,  from  minute  canals  which  can  hardly  be 
detected  except  by  microscopic  examination  of  cut  sections  of 
the  bowel,  to  large  elongated  pouches  resembling  the  vermiform 
appendix  or  a  Meckel's  diverticulum.  They  are  sometimes 
round,  and  may  be  described  as  resembling  cherries,  but  more 
often  are  long  finger-like  pouches  with  a  somewhat  dilated 
extremity.  In  one  of  my  cases  the  largest  diverticulum  was 
about  2^  inches  in  length,  and  about  the  thickness  of  a  normal 
appendix  vermiformis.  It  passed  down  between  the  layers  of 
the  mesosigmoid,  and  the  opening  from  the  bowel,  which  was 
at  the  mesenteric  attachment  of  the  sigmoid,  easily  admitted 
a  large-sized  probe.  In  many  cases,  however,  they  are  much 
shorter  than  this,  and  will  admit  only  a  bristle  with  difficulty. 

The  commonest  situation  for  diverticula  is  near  the  mesenteric 
attachment  of  the  bowel ;  but  they  may  occur  at  any  position 
between  the  longitudinal  muscle-bands.     They  may  be   found 


l83 


PERICOLITIS 


on  the  free  edge  of  the  bowel  almost  opposite  the  mesenteric 
attachment.  It  is  not  uncommon  to  find  one  of  them  passing 
into  an  appendix  epiploica,  and  several  writers  have  concluded 
that  these  diverticula  are  simply  hollow  appendices  epiploicae 
which  communicate  with  the  bowel  lumen.  This  is  certainly 
not  the  case,  as  the  normal  appendices  epiploicae  are  simply 
small  accumulations  of  the  sub-peritoneal  fat  or  sub-peritoneal 


Fig,  47. — Drawing  of  the  pelvic  colon  in  a  man,  aged  62,  showing  numerous  diverticula.  One 
large  diverticulum  passed  down  between  the  layers  of  the  mesosigmoid  ;  its  e.\tremitj'  was 
dilated  and  contained  a  stercolith. 


hpomata,  and  have  no  connection  whatever  with  the  muscular 
coat  of  the  bowel,  and  certainly  not  with  the  mucous  membrane. 
The  diverticula  on  the  other  hand,  are  direct  protrusions  from 
the  bowel  lumen,  and  the  fact  that  they  may  sometimes  be 
found  passing  into  an  appendix  epiploica  must,  I  think,  be 
looked  upon  as  merely  a  fortuitous  circumstance. 

They  occur  at  just  the  positions  where  the  appendices  are 


PERICOLITIS  183 

commonly  found,  and  it  is  probable  that  in  seeking  a  line  of 
least  resistance  in  which  to  extend  their  growth  they  readily 
find  their  way  into  the  appendices.  In  point  of  fact  they  are 
frequently  found  to  lead  into  the  appendices,  and  they  then 
become  distended  into  a  bulbous  end  which  remains  connected 
to  the  bowel  lumen  by  a  narrow  channel.  Not  infrequently 
they  push  down  between  the  layers  of  the  mesosigmoid,  and 
may  then  reach  a  considerable  length. 

In  Charing  Cross  Hospital  Museum  there  is  a  beautiful 
specimen  of  a  colon  showing  these  diverticula  occupying  the 
cippendices  epiploic^.  The}"  open  into  the  bowel  lumen  between 
the  \'alvute  conniventes  by  openings  which,  in  most  cases, 
will  admit  the  tip  of  the  little  finger.  The  ends  of  the  diverti- 
cula are  dilated  into  pouches  occupying  the  appendices  epiploicae. 
Most  of  the  fat  previously  present  in  the  appendices  has  been 
absorbed,  but  in  some  of  them  a  thin  layer  of  fat  still  remains 
separating  the  diverticulum  from  the  peritoneal  covering.  In 
this  specimen  there  appears  to  be  very  little  thickening  or 
inflammation  around  the  colon. 

These  diverticula  are  true  protrusions  of  the  bowel  ;  and  at 
first,  and  before  secondary  changes  have  occurred  in  them,  all 
the  coats  of  the  colon  are  represented  in  their  walls,  except 
occasionally  the  muscular  coat.  Presumably,  when  the  muscular 
coat  is  not  represented,  the  pouching  has  occurred  between 
the  fasicuH  of  the  muscle,  and  thus  has  not  carried  the  muscular 
coat  with  it.  In  a  considerable  number,  however,  the  muscular 
coat  can  be  demonstrated  in  the  wall  of  the  diverticulum.  As 
it  enlarges,  and  as  secondarv  inflammatory  changes  occur  in 
its  walls,  any  muscular  tissue  atrophies,  so  that,  in  the  later 
stages,  no  trace  of  any  muscular  tissue  can  be  detected. 

Edel  has  demonstrated  the  presence  of  a  muscular  coat  to  be 
quite  frequent  on  microscopical  examination,  and  this  was  also 
shown  in  one  of  Mo\Tiihan's  cases.  In  one  of  my  own  cases 
the  remains  of  the  muscular  coat  could  be  clearly  seen  on 
microscopical  examination. 

The  diverticula  are  always  lined  by  mucous  membrane, 
though  this  may  be  much  changed  from  secondary  inflam- 
mation. There  is  usualh'  a  thick  layer  of  fibrous  tissue  in  their 
walls,  due  mostly  to  inflammation.  Outside  they  are  covered 
by  peritoneum,  and  if  they  have  passed  into  an  appendix,  there 
mav  be  a  laver  of  fat. 


-i84 


PERICOLITIS 


They  would  appear  from  post-mortem  statistics  to  be  very 
rare,  out  of  12,115  necropsies  collected  from  three  hospitals, 
diverticula  of  the  colon  were  only  present  in  28.  But  it  is 
highly  probable  that  they  are  nothing  like  so  rare  as  these  figures 
seem  to  show.  I  have  been  able  to  find  58  cases.  Graser,  who 
examined  microscopically  the  sigmoid  flexures  from  28  bodies 
of  elderly  persons,  found  small  diverticula  in  10. 

They  may  be  either  congenital  or  acquired,  but  are  certainly 
an  acquired  condition  in  the  vast  majority  of  cases.  This  is 
shown  by  the  fact  that  pericolitis  due  to  diverticula  apparently 
does  not  occur  in  childhood,  but  on  the  other  hand  is  chiefly 
confined  to  elderly  people.  I  have  been  entirely  unable  to  find 
a  single  instance  by  examining  the  colons  of  children  and  infants. 


Fig.  48. — Diagram  of  a  diverticulum  of  the  colon.    _  (A)   Interior  of  colon.       (B)  Cavity  of 
diverticulum.      (C)  Stercolith.      (D)  Appendix  epiploica.      (E)  iMuscnlar  coat  of  colon. 


Diverticula  are  not  peculiar  to  the  colon,  but  may  occur  in  the 
small  intestine,  apart  from  Meckel's  diverticulum.  They  are 
not  found  in  the  caecum,  and  but  rarely  in  the  ascending  and 
transverse  colon.  The  commonest  situation  is  in  the  lower 
part  of  the  descending  colon,  and  more  especiall}^  in  the  sigmoid 
flexure. 

They  never  occur  in  the  rectum,  probably  because  of  the 
thicker  muscular  coat  of  the  latter  viscus. 

They  may  be  single,  but  in  most  cases  are  multiple.  In  man}- 
of  the  cases  great  numbers  of  these  diverticula  are  present. 

It  is  interesting  to  notice  that  in  a  case  recorded  by  Rolleston 
there  was  a  pressure  diverticulum  of  the  pharynx  in  addition 
to  diverticula  in  the  sigmoid  flexure.     Acquired  diverticula  of 


PERICOLITIS  185 

the  colon  generally  contain  fecal  material :  in  fact  one  might  say 
that  they  invariably  do  ;  and  it  is  to  their  contents  rather  than 
to  themselves  that  the}/  owe  their  pathological  significance. 
In  many  cases  the  fecal  material  has  become  hardened  from 
long  residence  within  the  pouch,  and  has  formed  a  concretion 
or  stercolith.  In  one  of  my  cases  the  concretion  was  of  the  size 
and  consistence  of  a  date-stone.  They  are  generally  found  in 
the  pouched  extremity  of  the  diverticulum. 

The  cause  of  the  formation  of  these  diverticula  has  been  the 
subject  of  considerable  discussion  ;  but  there  is  little  doubt  they 
are  simply  pressure  herniae  of  the  mucous  membrane,  produced 
in  most  cases  by  old-standing  constipation. 

The  youngest  case  in  which  they  have  been  found  is 
Fielder's,  of  a  patient  aged  22.  In  most  the  subjects  are 
elderly.  In  80  cases  collected  by  Telling,  the  average  age  was 
60,  and  in  my  series,  is  about  the  same.  This,  and  the  fact 
already  referred  to,  that  post  mortem  they  are  not  found  in 
children,  but  only  in  adults,  and  chiefly  in  elderly  adults, 
point  to  some  long-continued  cause,  associated  probably  with 
weakening  of  the  musculature  of  the  gut-wall  from  atrophy. 

The  fact  that  chronic  constipation  is  present  in  most  of  the 
cases  in  which  diverticula  are  found,  combined  with  the  other 
fact  that  they  are  commonest  in  the  sigmoid  flexure,  which  we 
know  to  be  the  chief  receptacle  for  faecal  material,  and  certainly 
that  portion  of  the  bowel  in  which  the  contents  are  longest 
retained,  seems  to  support  the  view  that  constipation  is  an 
important  etiological  factor.  But  it  must  not  be  forgotten 
that  constipation  is  very  common  without  the  formation  of 
diverticula.  Also,  if  constipation  were  the  only  cause,  we 
should  expect  to  find  diverticula  more  frequently  present  in 
women  than  men  ;  but  the  reverse  is  apparently  the  case. 
While,  therefore,  it  cannot  be  doubted  that  constipation  is  an 
important  factor,  there  must  be  some  other  cause  to  account 
for  their  formation. 

A  fact  of  some  importance,  first  noticed  by  Klebs,  is  that  the 
commonest  situation  for  the  diverticula  is  along  the  edge  of 
the  mesenteric  attachment,  which  is  also  the  position  at  which 
the  blood-vessels  of  the  gut  pierce  the  muscular  coat.  These 
are  obviously  points  of  weakness  in  the  bowel  wall,  but  on  the 
other  hand  many  of  the  diverticula  occur  on  the  convexity  of 
the  bowel,  where  there  are  no  vessels  entering. 


i86  t'ERIGOLITIS 

I  think  the  probable  explanation  of  the  formation  of  these 
pouches  is  that  they  are  true  pressure-herniae  through  a  weakened 
muscular  wall  produced  by  chronic  constipation.  They  are  a 
kind  of  exaggeration  of  the  normal  sacculi  of  the  colon  occurring 
between  the  longitudinal  muscle-bands.  That  pressure  is  not 
the  sole  cause  is  evident  from  the  fact  that  they  are  not  commonly 
found  above  a  stricture  of  the  rectum,  as  one  would  otherwise 
expect. 

I  have  seen  one  case  in  which  a  large  diverticulum  was  present 
in  the  upper  part  of    the    sigmoid    above    a    rectal    stricture 


Fig.  49. — Section  of  the  wall  of  the  colon  in  a  case  of  pericolitis  due  to  multiple  diverticula. 


(carcinoma)  ;  but  although  I  have  collected  a  large  number  of 
cases  of  these  diverticula,  I  have  found  no  other  such  instance. 

Pathological  Changes  in  Acquired  Diverticula  of  the  Colon 
which  may  cause  Pericolitis. — The  pathological  conditions  which 
may  occur  in  one  of  these  diverticula  are  practically  identical 
with  those  which  may  occur  in  the  vermiform  appendix. 

Once  formed,  the  pouch  tends  to  enlarge  and  to  elongate 
beneath  the  peritoneum.  Faecal  material  will  find  its  way  into 
it,  but  will  not  readily  get  out  again,  with  the  result  that  a 
concretion  is  soon  formed.     The  muscular  coat,  if  present,  soon 


PERICOLITIS 


187 


atrophies  and  the  mucous  membrane  becomes  thinned  or 
ulcerated,  so  that  in  their  later  stages  the  pouches  have  very 
thin  walls  consisting  of  little  more  than  peritoneum.  As  with 
the  appendix,  the  presence  of  the  feecal  concretion  readily  sets 
up  ulceration  in  the  interior  of  the  diverticulum,  and  we  thus 
have  inflammation  of  the  wall  of  the  diverticulum,  and  all  the 
factors  necessary  for  the  production  of  an  abscess  or  perforation. 
Perforation  may  result  either  from  sloughing  of  the  concretion 
through  the  walls  of  the  diverticulum  (and  in  one  or  two  cases 
the  concretion  has  been  found  loose  in  the  peritoneal  cavity), 
from  gangrene  of  the  diverticulum,  or  from  the  formation  of  a 
local  abscess  which  has  subsequently  burst  into  the  peritoneal 
cavit\\     Examples  of  all  these  conditions  are  to  be  met  with. 


Fig.  50. — Tuberculous  pericolitis  producing  a  stricture.     The  stricture  is  ulcerated, 
and  the  colon  above  dilated. 


Occasionally  a  chronic  pericolitis  is  set  up  which  results  in 
the  formation  of  a  dense  mass  of  fibrous  tissue  around  the 
■diverticula,  protecting  them  from  perforating,  but  causing  a 
dense  cicatricial  mass  which  may  result  in  obstruction  of  the 
bowel,  and  w^hich  may  closely  simulate  malignant  disease. 
Apart  from  the  presence  of  concretions,  diverticula  may  contain 
foreign  bodies,  and  two  cases  are  recorded  by  Bland  Sutton 
•of  an  inflamed  diverticulum  of  the  sigmoid  which  contained  a 
piece  of  straw. 

Several  illustrations  of  diverticula  and  of  their  microscopic 
appearance  are  appended. 

In  one  of  the  cases,  a  diverticulum  of  the  caecum  had  become 


i88  PERICOLITIS 

infected  with  tubercle  and  caused  tuberculous  ulceration  of  the 
ascending  colon. 

2.  Ulcer ATiox. — Any  form  of  ulceration  of  the  colon  may  cause 
pericolitis.  The  ulcers  may  be  either  single  or  multiple.  The\' 
are  generally  of  old  standing,  and  have  either  perforated  the 
bowel-wall  or  are  covered  on  the  outer  side  by  peritoneum  only. 
They  are  often  cratiform,  and  the  colon  at  the  base  of  the  ulcer 
has  become  adherent  to  other  structures,  or  is  densely  matted 
over  with  fibrous  tissue.  In  one  of  my  cases  in  which  the  mucous 
membrane  of  the  sigmoid  was  extensively  ulcerated,  the  bowel- 
wall  was  so  thick  and  hard  as  to  suggest  at  first  that  it  was  the 
site  of  an  infiltrating  carcinoma,  which  view  was  apparently 
supported  by  the  presence  of  numerous  enlarged  glands  in  the 
mesosigmoid.  A  careful  examination,  however,  showed  that 
the  thickening  of  the  bowel-wall  was  entirely  secondary  to  the 
ulceration,  and  that  the  gland  enlargement  was  inflammatory. 

3.  Perforation  by  Foreign  Bodies. — These  may  be  either 
pins,  fish-bones,  or  other  sharp  bodies  which  have  been  swal- 
lowed, or  foreign  bodies  introduced  into  the  rectum.  A  case 
was  recently  reported  in  one  of  the  medical  journals,  of  a  girl 
who  had  swallowed  a  packet  of  needles  ;  several  of  these  were 
found  to  have  reached  the  colon  and  perforated  its  walls, 
producing  local  adhesions  and  inflammation,  but  without 
causing  a  general  peritonitis. 

A  case  is  recorded  by  Cuff,  in  which  a  piece  of  straw,  used  by 
the  patient  for  picking  his  teeth,  was  swallowed  and  perforated 
the  colon.  A  chronic  pericolitis  occurred,  and  a  hard  mass 
formed  in  the  abdomen  and  became  adherent  to  the  abdominal 
wall,  and  discharged  pus.  The  pus  was  found  on  examination 
to  contain  the  ray  fungus  :  so  that  in  this  case  the  pericolitis 
was  due  to  actinomycosis. 

4.  5.  Tubercle  and  Cancer. — These  causes  of  pericolitis 
will  be  considered  in  detail  in  Chapters  XIV  and  XVIII. 

6.  Syphilis. — This  does  not  appear  to  be  a  usual  cause  of  peri- 
colitis. It  is  mentioned,  however,  by  one  or  two  writers  on 
the  subject,  and  Cavaillon  and  Bardin  have  recorded  four  cases. 

7.  Traumatism. — The  colon  is  not  readily  subject  to  injury 
from  direct  violence,  and  it  is  difficult  to  prove  that  a  peri- 
colitis has  arisen  directly  as  the  result  of  an  injury.  In  two 
cases  recorded  by  D'Arcy  Power,  there  was  a  definite  history 
of  abdominal  traumatism.     In  one,  a  woman  had  been  kicked 


PERICOLITIS  189 

in  the  abdomen,  and  in  the  other  the  patient  had    been  struck 
in  the  abdomen  wliile  at  work. 

In  one  or  two  other  instances  there  are  also  liistories  of 
abdominal  injury,  but  in  none  of  them  was  any  tear  or  injurj^ 
of  the  colon  demonstrated. 

Symptoms. 

These  vary  greatly,  according  to  the  cause  of  the  condition 
and  the  degree  of  inflammation  present.  From  a  clinical  point 
of  view  we  may  distinguish  two  distinct  types  :  cases  in  which 
there  is  tumour  formation,  and  those  in  which  there  is  abscess. 
Thus  in  many  patients  the  condition  first  draws  attention  to 
itself  by  the  presence  of  a  tumour  in  the  abdomen,  in  others 
by  signs  of  an  intra-abdominal  abscess,  or  by  perforation  and 
general  peritonitis,  while  in  a  few  the  onset  of  intestinal 
obstruction  is  the  first  evidence  of  anything  being  wrong. 

Interest  has  chiefly  centred  round  those  cases  in  which  a 
tumour  forms  in  some  part  of  the  colon,  as  these  tumours  so 
closely  simulate  cancer  of  the  bowel  that  they  are  usually 
mistaken  for  it.  It  is  interesting  in  this  connection  to  notice 
that  many  cases  of  supposed  spontaneous  disappearance,  or 
cure  without  operation,  of  cancer  of  the  bowel,  are  without 
doubt  in  reahty  pericolitis  in  which  the  tumour  has  been  mis- 
taken for  cancer. 

These  tumours  are  due  to  thickening  of  the  bowel-wall  from 
chronic  inflammation.  They  grow  slowly,  and  are  often  very 
hard,  due  to  the  deposit  of  fibrous  tissue,  so  that  it  is  usually 
impossible  from  the  symptoms  to  distinguish  them  from 
malignant  disease.  Short  of  a  microscopical  examination,  they 
cannot  be  diagnosed  from  cancer  except  in  a  few  instances 
where  the  history  may  assist  us,  as  in  the  following  case  :— 

Case. — Tlie  patient  was  an  elderly  lady  whom  I  saw  in  consulta- 
tion with  her  medical  attendant  with  a  view  to  the  possibility  of 
closing  a  colotomy  opening  of  five  years'  standing.  There  was  a 
history  that  about  six  years  ago  she  commenced  to  have  great 
difficulty  in  getting  the  bowels  open.  This  gradually  increased 
until  it  terminated  in  an  attack  of  acute  intestinal  obstruction. 
For  the  relief  of  this  a  left  inguinal  colotomy  was  performed,  and 
at  the  operation  a  large,  hard,  nodular  tumour  was  discovered  in 
the  sigmoid  flexure.  This  tumour  was  diagnosed  as  a  large  in- 
operable cancer,  and  the  patient  was  not  expected  to  live  more  than 
a  few  months.     After  the  operation  she  got  better,   and  had   no 


190  PERICOLITIS 

symptoms  beyond  those  occasioned  by  the  inconvenience  of  the 
colotomy  opening.  At  the  time  I  saw  her,  five  years  after  the 
operation,  she  was  in  good  health,  and  as  some  faecal  material  passed 
by  the  anus  it  was  hoped  that  the  colotomy  opening  might  be  closed. 
A  sigmoidoscopic  examination  showed  the  rectum  and  lower  part 
of  the  sigmoid  to  be  normal,  but  above  this  the  bowel  was  fixed, 
and  there  was  a  large  mass  in  the  bowel  wall.  From  the  colotomy 
opening,  a  large,  hard,  nodular  mass  could  be  felt  in  the  bowel  wall, 
but  not  invading  the  mucosa.  It  was  firmly  fixed,  and  adherent 
to  the  left  iliac  fossa.  Just  below  the  colotomy  opening  there  was 
a  tight  stricture  of  the  colon  which  would  barely  admit  the  tip  of 
my  index  finger.  The  patient  had  never  passed  any  blood,  or 
experienced  any  symptoms  pointing  to  ulceration  of  the  mucosa. 
There  is  Httle  doubt  that  this  was  a  case  of  chronic  pericolitis,  due 
probably  to  diverticula. 

In  the  more  acute  cases,  where  there  is  abscess  formation, 
the  symptoms  are  exactly  the  same  as  those  of  appendicitis, 
except  that  the  situation  is  different.  Several  of  these  have 
been  described  as  appendicitis  on  the  left  side  of  the  abdomen. 
There  is  a  high  or  intermittent  temperature,  with  rigors  and 
sweats  ;  pain,  localized  to  some  part  of  the  colon,  and  local 
peritonitis.  A  tender  swelling  may  be  present,  and  there  may 
be  fluctuation  in  this  on  careful  palpation.  The  abdominal 
wall  is  rigid,  and  the  patient  lies  with  the  legs  drawn  up  and  in 
considerable  pain.  If  perforation  has  occurred,  the  usual 
symptoms  of  commencing  general  peritonitis  will  show  them- 
selves. An  exact  diagnosis  is  seldom  possible,  but  when  we 
see  a  patient  with  all  the  symptoms  of  appendicitis,  but  with 
the  signs  localized  to  some  other  part  of  the  abdomen  than  the 
appendix  region,  we  should  be  suspicious  of  this  condition. 

The  following  is  a  good  instance  of  pericolitis  with  perforation  : 

Case. — A  caretaker,  aged  57,  was  admitted  to  St.  George's 
Hospital  with  symptoms  of  acute  general  peritonitis.  There  was 
a  history  of  sudden  abdominal  pain  following  a  dose  of  castor  oil. 
On  opening  the  abdomen  it  was  found  that  the  appendix  was  not 
the  cause  of  the  peritonitis,  but  the  colon  in  the  left  iliac  fossa  was 
bound  down  by  adhesions  and  was  perforated.  The  abdomen  was 
drained,  but  the  patient  died  in  a  few  hours.  The  autopsy  revealed 
old  adhesions  and  thickening  of  the  pelvic  colon,  and  a  diverticulum 
which  had  perforated  into  the  peritoneal  cavity.  There  were 
numerous  diverticula  throughout  the  colon. 

The  following,  which  is  a  good  instance  of  pericolitis  with 


PERICOLITIS  191 

abscess  formation,  is  recorded  by  Mr.  D'Arcy  Power  {Brit.  Med. 
Joiirn.  Nov.  3rd,  1906)  : — 

Case. — The  patient,  a  married  woman,  aged  38,  was  admitted 
to  the  Bolingbroke  Hospital,  complaining  of  pain  and  a  lump  in 
her  stomach.  There  was  a  history  of  her  having  been  kicked  in 
the  abdomen  on  several  occasions.  Ten  days  before  admission 
she  was  seized  with  severe  abdominal  pain  quite  suddenly  while  at 
work.  During  the  following  week  the  pain  continued,  and  on  one 
occasion  she  vomited.  The  bowels  were,  however,  relieved  daily. 
At  the  end  of  the  week  she  suddenly  became  worse,  and  her  tem- 
perature rose.  On  admission,  her  pulse  was  128  and  her  temperature 
102°  F.  The  left  side  of  the  abdomen  was  rigid  and  tender,  and  a 
tumour  could  be  felt  to  the  left  of  and  above  the  umbilicus.  The 
abdomen  was  resonant  over  the  swelling.  A  blood-count  showed 
a  marked  leucocytosis. 

The  abdomen  was  opened  over  the  swelling,  and  a  large  abscess 
was  found  extending  backwards  to  the  posterior  abdominal  wall, 
and  downwards  along  the  inner  side  of  the  descending  colon.  The 
abscess  was  drained,  and  the  patient  made  a  good  recovery. 

THE     PATHOLOGICAL     CONDITIONS     ARISING 
FROM     PERICOLITIS. 

Pericolitis  may  give  rise  to  any  of  the  following  pathological 
conditions:  (i)  Tumour  or  swelling;  (2)  Abscess  ;  (3)  Stricture 
of  the  colon  ;  (4)  Adhesions  to  other  organs  ;  (5)  Fistulce  ;  (6) 
Vesico-colic  fistulce ;  (7)  Cancer ;  (8)  General  peritonitis ; 
(9)  Deformities  and,  contractions  of  the  mesosigmoid. 

I.  Tumour  Formation, — Chronic  pericolitis  may  result  in  the 
formation  of  a  tumom"  which  to  the  naked  eye  is  indistinguishable 
from  a  malignant  growth,  and  in  many  instances  it  has  only  been 
on  microscopical  examination  that  the  true  pathology  of  the 
condition  has  been  detected. 

The  tumour  is  usually  very  hard,  irregular  in  shape,  and 
adherent  to  neighbouring  structures.  The  lymphatic  glands 
draining  the  affected  area  are  usually  enlarged. 

On  examination  after  removal,  either  as  the  result  of  an 
operation  or  "  post  mortem,"  evidence  of  inflammation  is 
usually  noticed.  The  mass  may  be  red  and  oedematous  in 
places,  while  here  and  there  white  patches  of  lymph  can  often 
be  seen,  which  mark  the  site  of  recent  adhesions  to  neighbouring 
structures.  The  peritoneum  is  usually  rough  and  much 
thickened.     When  cut  open  the  walls  are  seen  to  be  thickened 


192  PERICOLITIS 

and  indurated,  and  to  the  naked  eye  may  closely  resemble  a 
malignant  growth.  In  some  instances  the  wall  of  the  bowel 
has  been  an  inch  or  two  in  thickness,  and  intensely  hard. 
Thickening  is  due  to  inflammatory  infiltration  of  all  the  coats 
of  the  bowel,  and  subsequent  formation  of  fibrous  tissue.  In 
fact  the  entire  bowel-wall  may  be  converted  into  a  solid  mass 
of  fibrous  tissue  over  an  inch  in  thickness.  The  thickening  is 
not  confined  to  any  one  aspect  of  the  bowel-wall,  but  in  most 
cases  completely  surrounds  it,  though  it  is  often  considerably 
greater  in  one  part  than  another.  The  mucous  membrane 
may  be  almost  unaffected,  and  on  examination  be  quite  smooth  ; 
in  this  respect  it  differs  markedly  from  the  condition  usually 
seen  in  cancer.  The  presence  of  diverticula  or  ulcers  may 
often  be  detected  on  careful-  examination,  as  the  condition  has 
generally  arisen  from  some  cause  within  the  bowel. 

There  is  often  narrowing  of  the  bowel  lumen  at  the  site  of 
the  tumour,  and  this  may  have  resulted  in  secondary  ulceration 
in  the  bowel  above  the  stricture  from  faecal  retention.  This, 
however,  must  not  be  confused  with  the  primary  cause  of  the 
condition. 

The  stricture  itself  is  a  secondary  result  of  the  formation  and 
subsequent  contraction  of  the  fibrous  tissue  in  the  wall  of  the 
colon,  and  in  this  respect  closely  resembles  the  formation  of 
the  typical  ring  stricture  often  seen  in  cancer  of  the  colon. 
There  may  be  only  a  ring  stricture,  or  in  some  cases  a  long 
narrow  canal  is  formed.  In  some,  the  lumen  has  been  so 
narrowed  as  barely  to  admit  a  lead  pencil.  In  others,  however, 
considerable  tumour  formation  occurs,  with  but  little  narrowing 
of  the  bowel  lumen. 

Curiousl}^  enough,  the  mucous  membrane  may  not  be  involved 
at  all  in  the  inflammatory  process,  even  though  apparently  the 
condition  has  arisen  from  some  defect  in  the  mucous  lining  of 
the  canal.  Thus  in  one  case,  although  a  considerable  tumour 
existed,  and  the  walls  of  the  bowel  were  over  half-an-inch  thick, 
the  mucosa  showed  no  changes,  and  moved  freely  on  the  sub- 
jacent coat. 

The  thickened  walls  of  the  bowel  may  show  necrotic  or  break- 
ing down  areas,  but  this  is  the  exception  rather  than  the  rule. 
Careful  examination  of  the  walls  of  the  bowel  after  it  has  been 
cut  open  will  not  infrequently  reveal  the  presence  of  diverticula 
or  pouches,  usually  multiple,  and  often  very  narrow. 


PERICOLITIS  193 

Microscopical  Appearances. — The  tumour  is  generally  seen  to 
consist  mainly  of  a  dense  mass  of  fibrous  tissue  and  round-celled 
infiltration,  quantities  of  round  cells  being  interspersed  here 
and  there  throughout  the  mass.  At  the  areas  of  more  active 
or  recent  inflammation  the  ordinary  appearances  of  chronic 
inflammation  may  be  seen,  namely,  loose  connective  tissue 
crowded  with  lymphocytes.  Areas  containing  necrotic  tissue  or 
blood  extravasation  may  also  be  found.  The  peritoneum  shows 
chronic  inflammatory  changes,  is  usually  much  thickened,  and 
the  muscular  coat  much  atrophied.  The  mucosa  often  shows 
comparatively  httle  change,  but  in  some  cases  is  a  good  deal 
atrophied,  the  glandular  elements  having  disappeared. 

2.  Abscess, — This  is  a  not  uncommon  result  of  pericolitis. 
The  abscess  may  be  single,  or  there  may  be  a  large  indurated, 
mass  containing  numerous  small  abscesses. 

These  are  similar  to  abscesses  accompanying  appendicitis,  and 
are  usually  shut  off  from  the  general  peritoneal  cavity  by  adhe- 
sions to  neighbouring  coils  of  bowel.  The  abscess  may  be  post- 
peritoneal,  in  which  case  it  is  often  very  extensive,  surrounding; 
the  kidney,  and  passing  up  to  the  diaphragm  and  down  into, 
the  pelvis.  The  formation  of  a  post-peritoneal  abscess  seems, 
to  be  most  often  associated  with  pericoHtis  of  the  ascending 
colon.  They  may  burst  externally,  or  into  the  bowel,  or  may 
rupture  into  the  peritoneal  cavity  ;  instances  of  all  these  con- 
ditions have  been  met  with.  Such  abscesses  are  also  a  not 
uncommon  cause  of  vesicocolic  fistula.  As  is  the  case  with 
appendicitis,  they  may  result  from  an  actual  perforation  of  the 
bowel,  or  may  arise  without  any  perforation  being  detectable  : 
presumably  from  the  passage  of  micro-organisms  along  the 
lymphatics,  or  even  through  the  damaged  bowel-wall.  A 
common  cause  is  perforation  of  a  false  diverticulum  of  the 
colon. 

In  a  case  recorded  by  Telling,  acute  intestinal  obstruction 
had  resulted  from  the  small  bowel  becoming  adherent  to  a  mass 
of  pericolitis  in  the  sigmoid  flexure.  A  short-circuiting  operation 
was  performed,  but  the  patient  died.  It  was  then  found  that 
there  were  several  diverticula  in  the  sigmoid,  some  of  which 
had  perforated  and  caused  adhesions  to  the  ileum. 

Another  case  is  recorded  by  Moynihan,  in  which  also  the 
ileum  had  become  adherent  to  the  sigmoid  as  the  result  of 
pericolitis,  with  resulting  acute  obstruction.     The  patient  died 

13 


194  PERICOLITIS 

five  dav3  after  a  double  enterotomy  had  been  performed.  There 
is  a  specimen  in  Guv's  Hospital  Museum  of  a  band  between  the 
sigmoid  flexure  and  the  mesentery  of  the  ileum.  The  band  is 
formed  bv  two  adherent  appendices  epiploicae,  and  there  is 
some  thickening  of  the  wall  of  the  sigmoid.  The  patient  died 
from  intestinal  obstruction. 

Tuttle  records  a  case  of  chronic  obstruction  resulting  from 
Idnking  of  the  sigmoid  flexure  due  to  two  appendices  becoming 
adherent  to  each  other  as  the  result  of  local  pericolitis. 

3.  Stricture. — In  man}-  instances  a  fibrous  stricture  giving 
rise  to  obstruction  has  been  the  cause  of  death,  or  has  called 
for  the  performance  of  an  operation  for  its  reHef.  The  amount 
of  narrowing  of  the  colon  may  be  very  considerable,  and  as  the 
commonest  situation  for  the  condition  is  in  the  sigmoid  flexure, 
where  the  bowel  contents  are  usually  soKd,  obstruction  readih- 
occurs. 

4.  Adhesions. — Extensi\'e  adhesions  of  the  affected  portion 
of  bov.el  to  surrounding  structures  are  the  rule  in  pericolitis, 
and  are  nature's  method  of  protecting  the  patient  from  the 
consequences  of  the  condition. 

Favel  tells  of  a  woman  who  suffered  from  persistent  pain  in 
the  abdomen,  vs'hich  was  found  on  performing  laparotomy  to 
be  due  to  extensive  adhesions  between  the  ascending  colon  and 
the  anterior  abdominal  wall.  In  another  case,  in  which  the 
patient  suffered  from  constant  pain  and  frequent  vomiting, 
adhesions  were  found  between  the  ascending  colon  and  the 
abdominal  wall,  involving  also  the  uterus.  In  both  cases  the 
adhesions  had  arisen  from  a  localized  pericoHtis  of  the  ascending 
colon. 

Intestinal  obstruction  resulting  from  adhesions  produced  by 
pericolitis  may  occur,  and  is  generallv  due  to  adhesions  between 
the  small  intestine  and  the  colon. 

5.  Fistulae. — These  maj^  form  from  the  formation  of  an 
abscess  which  opens  upon  the  abdominal  wall,  producing  a 
cutaneous  fistula,  or  a  communication  may  take  place  into 
some  other  hoUow  viscus,  such  as  the  stomach  or  small 
intestine. 

6.  Vesico-colic  Fistula. — One  would  naturall}-  expect  peri- 
colitis, when  it  aft'ects  the  sigmoid,  to  be  a  common  cause  of 
adhesions  between  this  viscus  and  the  bladder,  with  which  it 
is  in  close  contact,    and   that   the  subsequent  formation   of    a 


PERICOLITIS  195 

fistula  between  the  two  would  be  a  not  uncommon  complica- 
tion. This  was  actually  present  in  sixteen  of  my  collected 
cases. 

There  is  an  interesting  example  in  Guy's  Hospital  Museum. 
The  patient  was  a  man  aged  65,  who  for  twelve  years  had  passed 
flatus  "  per  urethram."  More  recently  faeces  had  commenced 
to  escape  from  the  urethra.  Mr.  Bryant  performed  colotomy, 
but  the  patient  died.  Post  mortem  a  much  thickened  sigmoid 
flexure  was  found,  in  the  walls  of  which  were  numerous  diver- 
ticula. A  fistula  some  two  inches  in  length  established  com- 
munication between  the  bladder  and  the  sigmoid. 

Pericolitis  is  probably  the  commonest  cause  of  these  fistulas, 
as  was  pointed  out  by  Mr.  Harrison  Cripps  many  years  ago, 
when  he  showed  that  the  cause  was  inflammatory  in  45  cases 
out  of  63,  and  malignant  in  only  nine,  though  it  seems  generally 
believed  that  malignant  disease  is  the  commonest  cause  of 
these  fistulas.  Chavannaz,  from  a  study  of  95  cases,  came  to 
'the  conclusion  that  24  per  cent  only  were  due  to  malignant 
disease. 

Telling,  after  a  careful  investigation  of  the  subject,  concludes 
that  pericolitis  arising  from  diverticula  of  the  colon  is  the 
commonest  cause  of  these  fistulae,  and  points  out  that  this  much 
improves  the  prognosis  as  regards  operative  interference. 

7.  Cancer. — I  have  seen  one  case  in  which  there  was  a  cancer 
at  the  recto-sigmoidal  junction  associated  with  several  large 
diverticula  of  the  sigmoid,  and  pericolitis.  The  greater  part 
of  the  sigmoid  showed  considerable  simple  inflammatory  thicken- 
ing. It  was  impossible  to  be  certain  that  the  pericolitis  was 
the  primary  condition,  but  it  appeared  probable. 

A  case  was  reported  by  Hochenegg  in  1902  of  a  patient  with 
cancer  of  the  sigmoid  flexure.  The  whole  of  the  sigmoid  flexure 
being  the  site  of  numerous  diverticula  containing  feecal  con- 
cretions, he  assumed  the  cancer  to  have  arisen  from  the  irritation 
of  the  faecal  material  in  the  diverticula.  A  case  in  which  a 
carcinoma  of  the  splenic  flexure  was  associated  with  numerous 
diverticula  in  the  sigmoid  flexure,  and  in  which  the  appearances 
of  the  growth  suggested  it  had  arisen  from  a  diverticulum  in 
the  splenic  flexure,  is  reported  by  TelHng. 

We  know  that  carcinoma  of  the  appendix  may  occur  ap- 
parently as  the  result  of  chronic  inflammation  around  a  retained 
calculus  in  the  appendix,  and  it  seems  equally  probable  that  a 


196  PERICOLITIS 

similar  result  may  follow  a  chronic  pericolitis  from  retained 
fsecal  material  in  a  diverticulum  of  the  sigmoid  flexure. 

8.  General  Peritonitis. — General  peritonitis  is  a  common 
result  of  pericolitis,  and  the  usual  cause  of  death  from  this 
disease.  It  may  result  from  a  direct  perforation  of  the  wall  of 
the  colon  due  to  ulceration,  or  to  sloughing  of  the  end  of  a  diver- 
ticulum of  the  colon  from  rupture  of  a  pericolic  abscess  into 
the  peritoneal  cavity.  In  one  case  a  faecal  concretion  was  found 
loose  in  the  peritoneal  cavity,  and  on  the  anterior  aspect  of 
the  sigmoid  flexure  there  was  a  diverticulum  which  was  partly 
gangrenous. 

Most  cases  of  pericolitis  which  have  been  left  untreated  have 
died  of  general  peritonitis.  In  some  of  these  it  had  not  been 
possible  to  demonstrate  any  opening  through  which  infection 
could  have  reached  the  peritoneal  cavity,  and  the  abscess,  if 
present,  was  apparently  shut  off.  In  these  cases  we  must 
assume,  either  that  the  opening  had  been  overlooked,  had  been 
closed  again  before  death,  or  that  the  organisms  had  passed 
through  the  walls  of  the  abscess  without  perforation  being 
present. 

9.  Deformities  and  Contractions  of  the  Mesosigmoid. — It 
is  obvious  that  if  chronic  inflammation  occurs  in  and  around 
the  wall  of  the  sigmoid  flexure,  the  mesosigmoid  will  be  liable  to 
be  involved  in  the  subsequent  contraction  caused  by  organized 
fibrous  tissue.  This  arises  not  uncommonly,  and  the  meso- 
sigmoid may  be  shortened,  contracted,  or  otherwise  deformed 
to  a  considerable  extent  as  the  result  of  an  old-standing  peri- 
sigmoiditis. 

Such  contractions  may  be  of  no  consequence  to  the  function 
of  the  bowel,  but  occasionally  may  result  in  kinking  or  angu- 
lation of  the  sigmoid,  or  in  such  impaired  mobility  that  a 
serious  impediment  to  the  passage  of  the  faeces  results.  In 
this  way  actual  acute  obstruction — or  more  frequently  a  chronic 
obstruction — is  produced.  This  subject  has  already  been  con- 
sidered in  dealing  with  volvulus  and  angulation  of  the  pelvic 
colon. 

The  effect  of  a  meso-sigmoiditis  in  producing  obstruction, 
twists,  kinks,  and  other  deformities  has  been  pointed  out  by 
Reis,  Tixier,  and  Riedel.  Reis  beheves  that  the  meso-sigmoiditis 
is  produced  by  mesenteric  diverticula,  which  have  become 
inflamed,  but  no  direct  proof  of  this  point  is  recorded. 


PERICOLITIS  197 

Treatment  of  Pericolitis. 

To  judge  by  the  cases  I  have  been  able  to  collect,  pericolitis 
appears  to  be  a  very  fatal  disease,  70  per  cent  of  the  patients 
having  died  either  from  general  peritonitis,  obstruction,  abscess, 
or  pyaemia. 

This  high  mortality  must  not  be  attributed,  however,  to 
surgical  failures,  as  in  many  cases  no  operation  was  performed, 
but  rather  to  the  absence  of  a  correct  diagnosis.  The  successful 
treatment  of  pericolitis,  like  that  of  appendicitis,  depends  to  a 
very  large  extent  upon  correct  and  early  diagnosis  of  the 
condition.  The  great  majority  of  cases  hitherto  have  been 
diagnosed  only  at  an  operation,  or  as  the  result  of  a  post-mortem 
examination,  and  the  first  essential  of  successful  treatment  in 
dealing  with  this  disease  is  to  get  it  better  recognized,  and  to 
obtain  a  reasonable  probability  of  a  correct  diagnosis,  before 
the  case  has  advanced  too  far  for  operation  to  be  attended  by  a 
reasonable  possibility  of  success. 

Of  the  74  cases  which  I  have  been  able  to  collect,  35  were  not 
operated  upon,  and  39  were.  Of  those  that  were  not  operated 
upon  33  died,  and  only  2  recovered,  while  of  the  cases  operated 
upon  21  recovered  and  18  died. 

It  must,  however,  be  remembered  in  considering  these  figures 
that  a  diagnosis  has  seldom  been  made  except  as  the  result  of 
either  an  operation  or  a  post-mortem  examination,  and  that  in 
consequence  there  is  in  all  probability  an  undue  proportion  of 
deaths  among  the  unoperated  cases. 

These,  however,  show  clearly  that  there  is  little  to  be  hoped 
for  from  purely  medical  treatment,  a  view  supported  by  the  fact 
that  death  has  in  most  cases  been  due  to  general  peritonitis, 
a  condition  not  amenable  to  purely  medical  treatment.  The 
only  hope  is  clearly  in  early  operative  interference.  Of  the  cases 
operated  upon,  18  died,  that  is  to  say,  there  was  an  operative 
mortality  of  44  per  cent.  This  is  high,  and  should  be  much 
reduced,  but  it  is  not  surprising  when  we  consider  that  in  most 
instances  a  correct  diagnosis  was  not  made  previous  to 
operation. 

Also  in  several  cases  the  operation  was  merely  an  exploratory 
one,  and  the  abdomen  was  closed  without  anything  being  done. 
Of  5  cases  so  treated  4  died.  Again,  in  7,  colotomy  was  per- 
formed under  the  impression  that  the  case  was  one  of  inoperable 
cancer,  and  of  these  4  died. 


198 


PERICOLITIS 


The   accompanying  table  shows  the   results   of   the    various 
operations  that  have  been  performed  for  pericolitis. 


Nature  of  Operation. 

No  .  OF  Cases. 

No.  OF 

Deaths. 

Exploratory  Laparotomy    . 

Colotomy    i^^ 

Excision    ii    ■          .  . 

Drainage 

Division  of  adhesions 

Short-circuiting 

Various    .  . 

5 

7 

12 

5 
3 

2 

5 

4 
5 
3 

I 
0 
2 

3 

Colotomy  failed  because  in  all  but  one  of  the  cases  there  was 
an  abscess  in  connection  with  the  colon,  and  although  the 
colotomy  relieved  the  obstruction,  the  abscess  remained  and 
caused  peritonitis. 

Simple  drainage  appears  to  have  been  very  successful,  as  out 
of  5  patients  so  treated  4  recovered.  These  were  all  cases  of  a 
localized  abscess  in  connection  with  the  colon. 

Excision  of  the  entire  inflamed  portion  of  colon  was  performed 
12   times,  with  9  recoveries. 

The  causes  of  death  after  operation  were  as  follows  : — 

'     General  peritonitis                .  .  .  .  14  cases 

Pyaemia  (not  due  to  operation)  .  .  i  case 

Obstruction  (unrelieved)      .  .  .  .  i  case 

Cardiac  failure  (on  eighth  day)  .  .  i  case 

The  treatment  of  pericolitis  is  practically  the  same  as  for 
appendicitis,  and  as  with  the  latter  condition,  the  nature  of  the 
operation  must  to  a  large  extent  depend  upon  the  exact  patho- 
logical condition  present,  and  the  acuteness  or  otherwise  of  the 
disease. 

Very  frequently  the  symptom  necessitating  immediate 
operation  has  been  the  development  of  a  local  or  general  peri- 
tonitis, due  either  to  abscess  formation,  or  to  perforation  of  the 
bowel  into  the  peritoneal  cavity. 

Localized  Abscess. — The  obvious  treatment  is  to  open  the 
abscess  and  adequately  drain  it,  while  at  the  same  time  preserving 
as  far  as  possible  the  natural  adhesive  barriers  protecting  the 
general  peritoneal  cavity.  The  abscess  may  be  very  extensive, 
and  for  adequate  drainage  to  be  established  it  may  be  necessary 
to  make  a  counter-opening  in  the  loin. 


PERICOLITIS  199 

When  dealing  with  an  abscess  in  the  bowel-wall  there  may  be 
much  difficult}^  in  locating  it  owing  to  the  dense  mass  of  sur- 
rounding adhesions.  This  is  well  exemplified  by  several  of  the 
cases  in  which,  after  an  exploratory  laparotomy  had  been 
performed  without  any  abscess  being  discovered,  the  post-mortem 
examination  showed  such  to  have  been  present. 

Perforation  and  General  Peritonitis. — In  these  cases, 
though  a  careful  toilet  of  the  peritoneum  and  the  establishment  of 
adequate  drainage  may  suffice,  it  is  advisable,  if  possible,  to  find, 
and  close  by  sutures,  the  perforation  in  the  colon.  Where  the 
perforation  is  due  to  the  rupture  or  sloughing  of  a  diverticulum, 
the  perforation  may  not  be  single,  or  other  diverticula  may  be 
so  nearly  in  the  same  condition  as  to  threaten  to  perforate. 
Also  when,  as  often  happens,  the  perforation  has  occurred  in  a 
dense  mass  of  fibrous  tissue  and  adhesions,  very  great  difficulty 
may  be  experienced  in  closing  the  perforation. 

I  have  been  unable  to  find  a  single  instance  of  perforating 
pericolitis,  in  which  the  general  peritoneal  cavity  was  infected, 
which  has  been  successfully  operated  upon.  And  yet  in  no  less 
than  20  of  the  cases,  death  was  directly  due  to  general  peritonitis 
following  a  perforation  of  the  colon  directly  into  the  peritoneal 
cavity.  This  is  without  counting  those  cases  of  general  periton- 
itis due  to  the  secondary  bursting  of  an  abscess.  Perforation 
has  most  frequently  resulted  from  the  sloughing  or  rupture  of  a 
diverticulum,  usually  upon  the  free  border  of  the  sigmoid  colon. 

Intestinal  obstruction  was  the  cause  of  death  in  7  cases,  and 
pj/a^mia  in  3. 

The  best  results  have  been  in  cases  accompanied  by  tumour 
formation.  The  tumour  has  in  almost  every  instance  been 
diagnosed  as  carcinoma  previous  to  operation,  and  in  several 
instances  its  inflammatory  nature  has  remained  undetected 
until  a  microscopical  examination  has  been  made.  Here  again 
we  see  the  importance  from  the  point  of  view  of  treatment  of  a 
correct  diagnosis.  The  collected  cases  show  clearly  that  in 
quite  a  number  of  instances  the  surgeon  has  abandoned  the 
operation  under  the  impression  that  he  was  dealing  with  a 
hopeless  case  of  cancer  of  the  bowel ;  whereas,  had  he  known 
that  he  was  only  confronted  with  a  simple  inflammatory 
tumour,  he  might  have  successfully  resected  it. 

Out  of  12  cases  treated  by  resection  and  end-to-end  anasto- 
mosis, or  the  establishment  of  a  colotomy,  9  recovered. 


200  PERICOLITIS 

Moynihan  resected  seven  inches  of  the  transverse  colon  for 
pericoHtis,  and  subsequently  anastomosed  the  ends  in  one  case, 
and  in  another  resected  five  inches  of  the  sigmoid  flexure.  Mayo 
excised  eight  inches  of  the  sigmoid  in  one  case,  and  in  another 
ten  inches  of  the  descending  colon  and  sigmoid  flexure. 

REFERENCES. 

RoLLESTON. — Lancet.  April,   1905. 
Moynihan. — Edin.  Med.  Jour.  Mar.  1907. 
Roberts. — Brit.  Med.  Jour.  May  26,  1908. 
Brewer. — Amer.  Jour.  Med.  Sci.  Oct.   1907. 
Saillant. — Jour,  des  Praticiens,  July^   1906. 
Thomson. — Lancet,  Mar.  21,   1908. 
Telling. — Lancet,  Mar.  21,  1908. 


201 


Chapter    XIV. 

TUBERCULOSIS    OF    THE    COLON. 

Tuberculous  lesions  of  the  colon  are  not  uncommon.  Thus 
Eisenhardt,  out  of  i,ooo  tuberculous  subjects,  found  such  lesions 
of  the  intestine  in  56  per  cent ;  in  most  of  these  the  colon  was 
affected.  In  all  but  four  of  his  cases  the  condition  was  secondary 
to  phthisis.  Similarly,  Herscheimer  found  it  present  in  all 
but  one  out  of  58  cases  of  phthisis. 

In  considering  these  figures,  however,  it  must  be  taken  into 
consideration  that  practically  all  these  patients  had  either  died 
from,  or  were  under  treatment  for,  phthisis.  Also  they  only 
refer  to  the  ordinary  ulcerative,  and  usually  secondary,  form  of 
intestinal  tuberculosis.  There  can  be  no  doubt  that  this  form 
of  ulcerative  cohtis  is  a  common  secondary  complication  of 
phthisis,  and  the  infection  is  probably  caused  by  the  sputum 
which  is  swallowed. 

There  are  three  types  of  tuberculous  disease  of  the  colon  : — 

(i)  Where  it  forms  part  of  a  general  or  miliary  tuberculosis  ; 
(2)  Tuberculous  ulceration ;    (3)  Hyperplastic  tuberculosis. 

Tuberculous  Ulceration  of  the  Colon  (Tuberculous 
Colitis). — In  the  ulcerative  type,  the  infection  is  certainly 
secondary  in  most  cases  to  tuberculous  lesions  of  the  lungs  and 
air-passages,  or  the  higher  parts  of  the  alimentary  canal,  and 
is  due  to  direct  infection  of  the  mucous  membrane  with  tubercle 
bacilli.  I  have  been  unable  to  find  any  case  of  primary 
tuberculous  ulceration  of  the  colon,  and  it  seems  probable  that 
it  is  always  a  secondary  tuberculous  manifestation  due  to  direct 
infection.  In  not  a  few  cases  it  is  the  chief  lesion  which  calls  for 
treatment.  In  one  case  it  was  apparently  secondary  to  tubercle 
of  the  genito-urinary  tract.  Rarely,  however,  tuberculous 
ulceration  of  the  colon  may  exist  apart  from  evidence  of  general 
tuberculosis.  Cautley  has  recorded  the  case  of  a  girl,  four 
years  of  age,  who  had  been  ill  for  a  year.  During  six  months 
the  stools  had  been  frequent,  loose,  and  very  offensive,  and  for 


202  TUBERCULOSIS    OF 

two  weeks  they  had  contained  small  black  particles  of  clotted 
blood.  Vomiting  occurred  daily,  but  there  was  practically  no 
abdominal  pain  or  distention,  and  no  fever.  She  died  ;  and  at 
the  autopsy  two  tuberculous  ulcers,  causing  stricture,  were 
found  in  the  colon.  There  were  also  extensive  ulceration  of  the 
caecum  and  multiple  ulcers  in  the  small  intestine,  with  a  little 
adhesive  peritonitis  at  their  bases,  but  no  caseous  mesenteric 
glands.  A  small  old  caseous  nodule  was  found  at  the  apex  of  the 
left  lung. 

The  ulceration  in  these  cases  is  of  the  typical  tuberculous  type, 
with  overhanging  edges  and  a  raw,  unhealthy  base.  On  micro- 
scopic examination,  numerous  caseating  areas  can  be  seen,  and 
tubercle  bacilli  are  present  in  great  numbers.  The  ulcers  are 
usually  multiple,  and  often  extensive,  tending  to  encircle  the 
bowel  ;  as  a  rule  there  is  little  or  no  thickening  of  the  bowel-wall, 
in  which  respect  it  differs  markedly  from  the  hyperplastic  type 
of  lesion. 

Secondary  deposits  of  tubercle,  and  caseation  in  the  mesenteric 
glands,  are  common  ;  though  in  one  case  there  was  no  infection 
of  the  glands. 

The  ulcers  may  occur  in  any  part  of  the  colon,  but  are  most 
commonly  seen  in  the  csecum  and  ascending  colon.  The  ulcers 
may  perforate  the  bowel  wall,  and  cause  either  abscess,  fistula, 
or  general  peritonitis.  In  four  of  the  cases  of  perforating  ulcer 
of  the  colon  which  I  collected  the  ulceration  was  tuberculous. 

A  remarkable  case  is  reported  by  Grey  Turner*  in  which 
tuberculous  ulceration  of  the  ascending  colon  apparently  resulted 
from  infection  of  a  false  diverticulum  of  the  caecum.  The  wall 
of  the  diverticulum  was  infiltrated  with  tubercle,  and  the  ulcera- 
tion had  extended  into  the  surrounding  tissues. 

While  the  formation  of  a  stricture  as  the  result  of  tuberculous 
ulceration  of  the  ileum  is  common,  it  very  rarely  occurs  in  the 
colon.  Fistula  formation  is,  however,  not  uncommon.  The 
fistula  may  open  on  to  the  skin  surface,  into  another  part  of  the 
bowel  resulting  in  a  short  circuit,  or  into  the  vagina,  rectum,  or 
bladder. 

Hyperplastic  Tuberculosis  of  the  Colon. — The  hyper- 
plastic form  is,  apparently,  in  some  instances  a  primary 
tuberculous  lesion  ;    in  most  of  the  recorded  cases  there  were 

*  Lancet  Report,   i6,   1905. 


THE    COLON  203 

no  S5miptoms  of  tuberculosis  elsewhere,  and  in  two  or  three 
of  them  an  autopsy  was  made,  and  a  careful  examination  failed 
to  jeveal  any  other  lesion  of  the  kind.  Also  in  a  considerable 
number  of  the  hyperplastic  cases  there  is  no  ulceration  and  the 
mucous  membrane  is  intact.  It  is  a  very  disputed  point  in 
these  cases  whether  the  tubercle  bacillus  reaches  the  colon  wall 
from  the  bowel  lumen  or  by  the  blood-stream. 

Hyperplastic  tuberculosis  of  the  colon  is  definitely  a  surgical 
disease,  as  it  gives  rise  to  tumour  formation  and  stricture  of 
the  bowel,  and  the  only  rational  treatment  is  by  operation. 

It  has  been  repeatedly  "mistaken  for  cancer,  which  in  symptom- 
atology it  closely  resembles  ;  but  has  seldom  been  diagnosed 
previous  to  operation,  and  often  only  then  after  a  microscopical 
examination. 

The  lesion  is  very  rare  ;  there  is  not  a  single  specimen  in  the 
Royal  College  of  Surgeons  Museum,  and  it  is  not  mentioned  in 
most  surgical  or  medical  text-books. 

This  peculiar  form  of  intestinal  tuberculosis  was  first 
described  in  detail  by  Hartman  and  Pilliet  in  1891.  It  is  of 
particular  interest  for  two  main  reasons  :  First,  that  it  is  a 
manifestation  of  tubercle  quite  unlike  the  lesions  usually  met 
with  in  other  organs  ;  secondly,  because  it  is  quite  commonly 
mistaken  for  carcinoma  of  the  bowel.  In  fact,  there  is  little 
doubt  that  a  great  many  of  the  cases  of  supposed  cancer  of 
the  bowel  which  have  got  well  without  operation,  or  after 
such  operations  as  short-circuiting  or  colotomy,  were  really 
cases  of  this  disease.  They  will,  however,  be  referred  to 
again  later. 

There  is  much  difficulty  in  studying  this  disease,  as  it  is  hardly 
yet  recognized  generally,  and  consequently  cases  are  often 
described  under  some  other  heading,  or  simply  recorded  as  rare 
conditions  ;  in  many  no  proper  microscopical  examination  has 
been  made  for  tubercle  bacilli  in  the  tissues.  Though  the  condi- 
tion is  undoubtedly  a  rare  one,  I  have  been  able  to  find  many 
well-authenticated  cases. 

The  disease  appears  to  occur  with  about  equal  frequency  in 
the  two  sexes.  Thus,  out  of  my  series  of  100  cases,  47  were  males 
and  33  females.  In  Bernay's  71  collected  cases  there  wxre  40 
men  and  31  women.  Conrath  collected  77  cases,  and  found  36 
men  and  41  women. 

This  affection  chiefly  attacks  those  in  the  middle  period  of  life. 


204  TUBERCULOSIS    OF 

between  20  and  40  years  of  age.  This  corresponds  very  closely 
with  the  average  age  for  phthisis.  In  my  series  the  average 
age  is  32  ;  the  oldest  patient  is  78  and  the  youngest  7  years 
of  age. 

It  is  generally  localized  to  one  part  of  the  colon  ;  occasionally, 
however,  there  are  two  or  three  distinct  lesions  ;  and  in  a  few 
very  rare  cases  the  whole  or  a  large  part  of  the  colon  is  affected. 
It  may  arise  in  any  portion  ;  but  by  far  the  commonest  situa- 
tion is  the  caecum  and  lower  part  of  the  ascending  colon. 
The  appended  table  shows  the  distribution  in  my  collected 
series  of  100  cases  : — 


Sigmoid  flexure     .  . 

Caecum    .  . 

Caecum  and  ascending  colon 

Whole  colon 

Caecum,  ascending  and  transverse  colon 

Total 


39 
4 
3 


There  appears  to  be  no  explanation  why  the  caecum  is  the 
most  commonly  affected  portion. 

The  characteristic  feature  is  the  formation  of  a  tumour  in 
some  part  of  the  colon,  accompanied  by  stricture  of  the  bowel 
lumen.  The  disease  is  essentially  chronic,  the  inflammation 
encouraging  the  formation  of  fibrous  tissue  and  thickening, 
rather  than  caseation  or  ulceration.  In  many  cases  the  mucous 
membrane  is  quite  intact,  and  there  is  no  sign  of  ulceration.  The 
bowel- wall,  however,  becomes  in  time  greatly  thickened,  with 
the  formation  in  most  cases  of  a  definite  tumour.  Constriction 
and  stricture  of  the  bowel  may  ensue  and  cause  intestinal  obstruc- 
tion. Secondary  abscess  may  occur ;  but  this  is  unusual. 
Tuberculous  peritonitis  is  likewise  uncommon. 

The  disease  differs  very  much  from  common  tuberculous 
lesions,  and  resembles  certain  rare  cases  of  tubercle  of  the  skin 
and  larynx,  and  especially  those  cases  of  Hodgkin's  disease 
which,  post  mortem,  have  been  found  to  be  tuberculous. 

As  a  rule  there  is  a  single  tumour  ;  but  in  a  few  cases  there 
have  been  several.  Trendelenburg  has  reported  a  case  in  which 
there  were  five  distinct  strictures  of  the  colon  from  this  cause  ; 
and  Borch  one  in  which  there  were  four. 

Association  with  other  Tuberculous  Lesions. — As  a  rule, 
the  condition  of  the  colon  is  the  only  manifestation  of  tubercle 


THE    COLON  205 

to  be  found  ;    in  only  twenty-four  out  of  the  one  hundred  cases  I 
have  collected  was  there  any  evidence  of  tubercle  elsewhere.     In 
several  of  these  it  seems  almost  certain  the  other  lesion  was 
secondary  to  that  in  the  colon. 
Table  of  100  cases  : — 

No  other  tuberculous  lesion  .  .  .  .  76 

Tuberculous  cavity  in  lungs  or  scars  of  old  phthisis  iS 

Tuberculous  peritonitis        .  .  .  .  .  .  i 

Tubercle  of  tibia                   .  .  .  .  .  .  i 

of  genito-urinary  tract  .  .  .  .  2 

of  phalanges         .  .  .  .  .  .  i 

Tuberculous  ulcer  in  vagina  . .  .  .  i 


It  seems  evident,  therefore,  that  in  most  of  the  cases  the 
disease  is  a  primary  tuberculous  lesion. 

When  the  caecum  is  the  affected  region  the  appendix  is  not  as 
a  rule  primarily  involved,  though  it  not  infrequently  becomes  so 
secondarily. 

Morbid  Anatomy. 
The  most  characteristic  lesion  is  the  formation  of    a  tumour 


in  some  portion  of  the  colon.  The  most  usual  situationTif 
~Thii:kening"~isTocalized  to^gnirpart  of  the  colon,  is  the  caecum, 
especially  in  the  neighbourhood  of  the  ileocecal  valve.  Some- 
times, however,  the  transverse  colon,  or  sigmoid,  have  been 
alone  affected.  In  a  case  reported  by  Claude,  the  ascending 
and  descending  colon  were  affected,  but  the  transverse  colon 
was  free. 

In  others  the  greater  part  of  the  colon  has  been  involved,  and 
in  Lartigau's  case  the  greater  part  of  the  small  intestine  as  well. 
Commonly,  the  affected  portions  of  bowel  are  matted  in  a  mass 
of  fibrous  adhesions  and  enlarged  lymphatic  glands,  so  that 
often  a  large  tumour  is  produced. 

The  most  conspicuous  feature  is  the  thickening  of  the  colon 
wall,  which  is  very  marked  in  all  cases.  In  this  it  differs  widely 
from  other  forms  of  tubercle  of  the  bowel,  as  instead  of  there 
being  a  destruction  of  tissue  with  thinning,  there  is  usually  no 
ulceration,  but  great  thickening  and  new  formation.  The  bowel- 
wall  feels  firm  and  hard,  due  to  infiltration  with  round  cells  and 
the  deposit  of  fibrous  tissue.  This  spreads  equally  round  the 
.  circumference  of  the  bowel-wall,  so  that  in  extreme  cases  the 


206 


TUBERCULOSIS    OF 


bowel  is  converted  into  a  hard  tube  almost  resembling  a  gas-pipe  ; 
considerable  narrowing  of  the  lumen  follows  as  a  result  of  the 
disease  ;  and  in  most  cases  stenosis  results,  and  chronic  or  acute 
obstruction.  Stenosis  is  the  common  feature,  and  the  bowel 
lumen  may  be  so  completely  blocked  that  it  cannot  be  detected 
post  mortem.  Even  where  no  definite  stenosis  is  present, 
the  thickening  of  the  bowel-wall  ultimately  prevents  the  peri- 
staltic movements  from  taking  place,  and  obstruction  results 
from  this  cause. 

In  addition  to  the  formation  of  stenosis  by  h5^erplasia  of 
the  bowel-wall,  narrowing  of  the  lumen  may  occur  from  the 
contraction  of  ulcers,  and  from  kinking  of  the  bowel  by  the 
contraction  of  adhesions. 

Where   the   stenosis   and   thickening   are   local,    considerable 


Fig.  51. — Hyperplastic  tuberculosis  of  the  colon  (/I/?-.  Nash's  case). 


dilatation  of  the  colon  above  the  stricture  may  occur,  and 
secondary  stercoral  ulcers  may  form.  Commonly  the  mucous 
membrane  appears  normal  and  there  is  no  ulceration  or  breach 
of  the  surface.  Sometimes  the  mucous  membrane  is  ulcerated. 
This  is  most  frequent  where  there  is  stricture  of  the  bowel 
lumen,  the  ulceration  being  often  confined  to  the  strictured 
area.  This  has  led  some  observers  to  conclude  that  the  stricture 
is  the  result  of  ulceration,  which  it  certainly  is  not,  as  some  of 
the  cases  where  there  is  marked  stricture  show  no  ulceration. 
In  many,  the  ulceration  is  the  ordinary  form  of  septic  or 
traumatic  stercoral  ulcer  found  above  a  stricture  of  the  bowel. 
In  fact,  the  ulceration,  though  it  may  occasionally  be  tuber- 
culous, is  probably  most  often  a  secondary  result  of  the 
stricture. 


THE    COLON 


207 


The  mucous  membrane  is  usually  thickened,  and  may  show 
numbers  of  small  tubercles  scattered  over  its  surface. 

A  striking  feature  in  many  cases  has  been  the  formation  of 
polypoid  or  papillomatous  outgrowths  on  the  mucous  membrane. 
The  polypoid  growths  are  usually  pedunculated,  and  hang  free 
in  the  bowel  lumen.  Similar  sessile  tumours  are  sometimes 
present  in  addition,  which  suggests  that  this  is  the  early  form  of 
the  pedunculated  polypi.  Polypoid  growths  are  often  very 
numerous,  and  give  a  most  curious  appearance  to  the  bowel. 
They  vary  in  size  from  quite  small  round  polyps  to  those  as 
large  as  hazel-nuts.     They  are  covered  over  with  a  layer  of 


Fig.  52. — Hyperplastic  tuberculosis  of  the  colon.     The  bowel  has  been 
cut  open  longitudinally. 


epithelial  cells  similar  to  the  surrounding  mucous  membrane, 
and  their  centre  is  continuous  with  the  submucous  layer  of  the 
bowel-wall,  and  consists  of  connective  tissue  and  round-celled 
infiltration.  Occasionally  there  are  caseous  foci  in  the  centre 
of  these  polypoid  growths  which  may  in  places  have  ulcerated 
through  the  epithehal  layer. 

The  tumour  is  very  hard  and  densely  indurated.  The  peri- 
toneum, as  a  rule,  appears  normal  to  the  naked  eye,  though  in 
some  cases  it  is  covered  with  small  raised  tubercles  or  nodules 
of  a  reddish  colour. 

If  the  mass  is  cut  open,  the  walls  of  the  bowel  are  seen  to  be 


2o8  TUBERCULOSIS    OF 

greatly  thickened,  often  to  an  inch  or  more,  and  look  and  feel 
like  cartilage.  The  cut  section  has  often  a  curious  bluish-grey 
translucent  appearance,  and  a  glistening  surface.  The  muscular 
coat  is  generally  much  thickened  and  can  be  distinctly  seen. 

Often  the  greatest  thickening  is  in  the  subserous  layer,  which 
consists  of  greyish  translucent  fibrous  tissue  of  cartilaginous 
hardness,  with  irregular-shaped  areas  of  yellowish  tissue  here 
and  there. 

The  bowel  lumen  is  usually  markedly  strictured,  or  there  are 
outgrowths  into  it.  The  whole  tumour  is  often  very  vascular  ; 
in  some  cases  it  shows  areas  of  degeneration  or  caseation. 

Two  types  of  lesion  have  been  described,  the  submucous  and 
subserous,  according  as  the  thickening  and  induration  are  chiefly 
in  the  submucous  or  subserous  layers.  Both  conditions,  how- 
ever, may  be  seen  in  the  same  case,  and  there  seems  little  advan- 
tage in  making  a  distinction  between  these  two  forms. 

The  disease  often  so  closely  resembles  cancer  of  the  colon  that 
it  is  only  distinguished  from  it  on  microscopical  examination. 

Histology. — The  mucous  membrane  often  shows  little  if  any 
change  beyond  some  thickening.  Cells  undergoing  mucoid  or 
cystic  degeneration  are  not  infrequently  seen.  If  ulceration  is 
present,  the  mucous  surface  presents  a  mammillated  appearance, 
or  is  altogether  absent. 

Polypoid  growths,  if  present,  are  seen  to  be  outgrowths  from 
the  submucosa,  and  their  centres  are  continuous  with  it.  The 
epithelium  covering  them  is  the  same  as  the  normal  epithelium, 
except  where  ulceration  is  present,  or  unless  caseation  has 
occurred. 

The  submucosa  is  generally  markedly  thickened  by  round- 
celled  infiltration  and  the  formation  of  dense  fibrous  tissue. 
Tubercles  and  giant  cells  are  often  to  be  seen  in  this  layer  in 
considerable  numbers.  Large  polymorphonuclear  round  cells, 
and  coarsely  granular  eosinophile  cells  are  also  to  be  seen, 
especially  towards  the  mucous  membrane.  There  may  also 
be  caseating  tuberculous  foci  in  this  layer.  The  predomin- 
ating feature  is,  however,  round-celled  infiltration  with  fibrous 
tissue. 

There  is  always  much  thickening  of  the  muscular  coats,  due 
chiefly  to  small  round-celled  infiltration.  It  is  doubtful  whether 
there  is  really  any  increase  in  the  number  of  muscle  fibres  such 
as  would  constitute  a  true  hypertrophy.     Some  observers  claim 


THE    COLON  209 

that  there  is,  while  others  are  equally  emphatic  that  there  is  not. 
If  dilatation  has  occurred  above  the  stricture,  the  muscular  coat 
may  be  h\^ertrophied  ;  but  apart  from  this,  the  hypertrophy 
appears  to  be  due  chiefly  to  increase  in  the  connective  tissue 
between  the  fibres. 

The  subserous  layer  is  often  greatly  thickened  owing  to  new 
connective-tissue  formation.  There  is  a  dense  mass  of  fibrous 
tissue  and  small  round  cells.  There  are  numerous  new  blood- 
vessels, often  with  thick  walls. 

This  layer  often  contains  large  vacuolated  spaces  holding 
yellow  fatty  tissue.  Giant  cells  and  areas  of  caseation  are  much 
less  numerous  here  than  in  the  submucous  layer.  The  serous 
layer  shows  very  little  change,  though  it  may  be  much  thickened. 
Tubercle  bacilli  can  usually  be  found  in  the  submucous  layer  if; 
sections  are  carefully  stained  ;  compared  with  other  tuberculous, 
lesions,  however,  they  are  very  scant\^  They  may  be  found  in. 
large  numbers  in  a  section  from  one  part  of  the  tumour,  and  not 
at  all  in  a  section  from  another  ;  while  in  several  cases  they  have: 
been  looked  for  with  great  care  in  vain.  Portions  of  the  growth: 
have  in  several  instances  been  inoculated  into  animals  and. 
caused  tuberculosis. 

Symptoms. 

Tuberculous  ulceration  of  the  colon  gives  rise  to  the  ordinary 
symptoms  of  ulceration  of  the  bowel,  and  does  not  differ  in  this 
respect  from  the  non-tuberculous  forms  of  ulcerative  coHtis.  As 
already  stated,  it  usually  occurs  as  a  terminal  condition  in  the 
later  stages  of  tuberculosis  of  the  lungs.  The  occurrence  of 
diarrhoea  and  bloody  stools,  combined  with  well-marked  signs 
of  phthisis,  is  indicative  of  the  onset  of  this  condition. 
Occasionally  single  ulcers  may  form  and  perforate,  and  in 
a  few  instances  general  peritonitis  has  occurred  from  the  per- 
foration of  a  tuberculous  ulcer  in  the  colon. 

The  symptoms  of  hyperplastic  tubercle  of  the  colon  are  those 
of  a  chronic  pericohtis.  A  tumour  slowly  develops  in  the 
abdominal  cavity,  usually  in  the  csecal  region,  and  is  accompanied 
by  a  varying  amount  of  pain  and  tenderness.  In  some  cases, 
however,  there  is  Little,  if  any  pain,  and  the  tumour  is  the  only 
sign  of  anything  wrong.  Sooner  or  later  the  patient  either  has 
recurring  attacks  of  partial  obstruction,  or  an  acute  attack  of 
complete  obstruction.     In  a  large  number  of  instances  there  are 

14 


210  TUBERCULOSIS    OF 

sjnnptoms  of  tuberculosis,  either  in  the  lungs  or  elsewhere,  but 
in  about  a  quarter  the  condition  is  apparently  primary  in  the 
colon. 

It  is  obvious  that  the  symptoms  of  hyperplastic  tubercle  of 
the  colon  are  the  same  as  for  cancer  of  the  colon  ;  and  as  the 
latter  is  the  more  common  disease,  it  is  hardly  surprising  that 
the  vast  majority  are  diagnosed  as  cancer. 

In  hyperplastic  tubercle  of  the  colon  there  is  seldom  any 
bleeding ;  but  in  cancer,  while  bleeding  is  not  invariable,  it  is 
usual.  The  complete  absence  of  blood  in  the  stools,  even  on 
microscopical  examination,  is  slightly  in  favour  of  tubercle, 
more  especially  if  the  tumour  has  existed  for  some  time. 

Tubercle  bacilli  can  only  with  difficulty  be  discovered  in 
sections  of  the  colon  wall,  and  are  practically  never  found  in  the 
stools. 

Secondary  Lesions. — Stricture  is  an  almost  invariable  accom- 
paniment of  the  lesion.  It  is  due  mainly  to  the  contraction  of 
the  fibrous  tissue  in  the  bowel  wall,  and  sometimes  partly  to 
outgrowths  into  the  lumen.  The  amount  of  narrowing  of  the 
lumen  is  often  considerable,  and  the  bowel  may  be  almost 
blocked. 

Intestinal  obstruction  is  a  common  terminal  result.  As 
already  stated,  when  ulceration  is  present  it  is  probably  in  most 
cases  a  stercoral  ulceration  secondary  to  the  stricture,  though 
sometimes  due  to  caseation  of  the  submucous  layer  and  conse- 
quent destruction  of  the  mucous  membrane. 

Dilatation  and  hypertrophy  of  the  bowel  above  the  stricture 
is  common,  and  stercoral  ulcers  in  the  dilated  portion  of  bowel 
have  been  present  in  several  patients. 

In  one  case  recorded  by  Crowder  the  tumour  had  apparently 
undergone  secondary  malignant  change.  It  was  situate  in  the 
-caecum,  and  presented  the  typical  appearances  of  hyperplastic 
tuberculosis  with  giant  cells  and  tubercle  bacilli.  In  one  part 
the  epithelial  cells  had  penetrated  to  all  depths  of  the  tissue,  and 
there  were  masses  of  atypical  epithelial  cells  forming  tubercles. 
Apparently  the  tuberculous  lesion  was  the  primary  one,  and 
part  had  undergone  secondary  malignant  change. 

The  glands  are  usually  enlarged,  and  show  giant  cells  and 
caseating  areas  ;  but  in  several  cases  there  was  no  gland  enlarge- 
ment. In  many,  the  tumour  was  tied  down  by  dense  adhesions, 
and,  in  some,  abscess  and  fistula  had  formed.     These  complica- 


THE    COLON  211 

tions,  however,  generally  mark  an  advanced  stage  of  the  disease, 
when  stricture  and  secondary  ulceration  have  occurred,  and  are 
in  no  way  typical  of  the  condition. 

The  following  case  is  reported  by  Cumston.* 

Case. — The  patient  was  a  woman,  aged  87,  who  had  complained 
of  pain  in  the  right  iliac  fossa  for  eighteen  months.  She  also 
suffered  severely  from  constipation,  and  had  lost  flesh.  There  was 
a  large  mobile  tumour  in  the  right  side  of  the  abdomen.  On  opening 
the  abdomen,  a  tumour  in  the  caecum  was  discovered.  The  ceecum 
was  resected,  with  8  cms.  of  the  ileum  and  6  cms.  of  the  colon  ; 
the  ends  were  closed,  and  rejoined  by  lateral  anastomosis.  The 
patient  made  a  good  recovery,  and  was  well  nineteen  months  later. 

Examination  of  the  specimen  showed  a  cauliflower-like  tumour 
the  size  of  a  small  apple.  On  the  upper  aspect  of  the  ileocsecal 
valve  it  completely  obstructed  the  bowel  lumen.  The  cascal  walls 
were  much  thickened,  and  this  thickening  extended  for  some 
distance  into  the  colon.  The  mucous  membrane  was  intact.  There 
were  a  few  enlarged  glands  in  the  mesentery.  Microscopical 
sections  of  the  tumour  showed  the  appearances  of  tuberculosis. 

The  following  cases  were  reported  by  F.  S.  Kidd : — 

Case. — The  patient  was  a  girl,  aged  7.  Three  years  previously 
she  developed  an  ulcer  in  the  vagina,  which  appeared  to  be 
tuberculous,  and  a  faecal  fistula  formed.  Several  operations 
performed  with  the  object  of  closing  this  fistula  had  failed.  The 
abdomen  was  opened,  with  the  object  of  performing  colotomy,  and 
it  was  then  found  that  the  sigmoid  flexure  was  represented  by  a 
hard,  indefinite  mass  about  6  in.  long.  The  whole  mass  was  very 
vascular.  It  was  diagnosed  as  cancer,  and  was  brought  out  of 
the  abdomen,  and  an  artificial  anus  established.  A  few  days  later 
the  growth  was  cut  away.  The  child  recovered  with  an  artificial 
anus. 

Examination  of  the  specimen  showed  a  tight  stricture  two-and- 
a-half  inches  long.  There  was  some  ulceration  at  the  site  of  the 
stricture,  but  elsewhere  the  mucous  membrane  was  normal.  The 
subperitoneal  layer  of  the  bowel  wall  was  greatly  thickened,  and 
had  undergone  a  curious  transformation  into  pale  bluish  hyaline 
tissue  almost  as  hard  as  cartilage  ;  in  places  this  was  nearly  two 
inches  in  thickness.  Microscopical  sections  showed  fibrillae,  fibro- 
blasts, and  round-celled  infiltration.  There  were  also  numerous 
large  endothelial  cells.     Sections  were  stained  for  tubercle  bacilli, 

*  Annals  of  Surg.  Nov.   1907. 


212  TUBERCULOSIS    OF 

but  they  could  not  be  demonstrated  ;    the  condition  was,  however, 
evidently  hyperplastic  tuberculosis. 

Case. — The  patient  was  a  man,  aged  57,  who  died  of  intestinal 
obstruction.  Post  mortem  there  was  a  tuberculous  scar  at  the 
apex  of  the  right  lung.  At  the  lower  end  of  the  sigmoid  flexure 
there  was  a  hard  cartilaginous  mass  involving  the  bowel  and  causing 
a  long  narrow  stricture.  Examination  of  the  tumour  showed  the 
mucous  membrane  to  be  intact.  There  were  two  or  three  large 
polypoid  masses,  which  had  become  impacted  in  the  narrow  lumen 
and  caused  obstruction.  The  muscular  coat  was  hypertrophied, 
and  the  subperitoneal  coat  in  some  places  measured  as  much  as 
three  inches  in  thickness.  It  was  as  hard  as  cartilage.  ^Nlicro- 
scopical  sections  showed  fibrillar  tissue  and  fibroblasts.  There 
was  much  small-celled  infiltration,  with  numerous  large  poly- 
nuclear  cells. 

"Gas-Pipe  Colon." — There  are  a  few  very  rare  cases  of 
hyperplastic  tuberculosis  of  the  colon  in  which  the  whole  or 
the  greater  part  is  uniformly  thickened  and  densely  indurated, 
and  for  want  of  a  better  term  I  have  called  these  cases 
"  gas-pipe  colon,"  owing  to  the  resemblance  of  the  bowel  to 
a  piece  of  iron  gas-pipe. 

I  have  been  able  to  collect  four  of  these  curious  cases,  one  of 
which  I  saw  myself,  and  three  are  from  other  sources.  The 
close  resemblance  between  the  four  makes  it  certain  that 
they  were  all  of  the  same  nature.  One  was  reported  as  a 
case  of  diffuse  carcinoma ;  but  it  seems  certain,  from  the 
resemblance  to  the  others  and  from  the  fact  that  symptoms 
had  existed  for  fourteen  years,  that  it  was  really  hyperplastic 
tuberculosis. 

In  my  case  the  patient  was  a  lady,  aged  72,  who  was  supposed 
to  be  suffering  from  intestinal  obstruction  due  to  cancer  of 
the  rectum  ;  some  resistance  could  be  felt  high  up  in  the  bowel. 
On  opening  the  abdomen  to  perform  colotomy,  it  was  discovered 
that  the  entire  large  bowel,  from  the  rectum  to  the  cacum, 
consisted  of  a  hard  tube  with  non-collapsible  walls,  resembhng 
more  than  anj^thing  else  a  piece  of  iron  gas-pipe.  The  colon 
was  diminished  in  size,  being  barely  an  inch  in  diameter  in  many 
places.  It  was  bound  down  to  the  posterior  wall  of  the  abdomen, 
and  everjAvhere  quite  immovable.  The  walls  of  the  colon  were 
as  hard  as  stone,  and  nodular.  The  peritoneal  surface  of  the 
bowel  was  covered  over  with  small  pink  tubercles,  and  there  was 


THE    COLON  213 

much  ascites.  The  wall  of  the  caecum  was  greatly  thickened  ; 
but  not  in  the  same  way  as  the  rest  of  the  bowel.  The  lumen 
was  evidently  patent,  because  the  bowels  had  acted  occasionally 
for  some  weeks,  and  slightly  the  day  before  the  operation.  The 
small  bowel  was  normal. 

Colotomy  could  not  be  performed  ;  but  a  Paul's  tube  was  tied 
into  the  c^cum  with  difficulty.  The  patient  died,  but  no  post- 
mortem was  obtainable. 

The  most  complete  case  is  Lartigau's.  The  patient  was  a 
man,  aged  49,  who  died  after  a  three  years'  illness.  The  thicken- 
ing of  the  bowel  wall  commenced  in  the  upper  third  of  the  ileum , 
and  extended  throughout  the  colon  to  the  commencement  of  the 
sigmoid  flexure.  The  wall  of  the  bowel  was  27  cms.  thick,  and 
uniform  throughout.  The  lumen  was  patent,  and  contained 
numerous  papillomatous  masses.  Microscopical  sections  of  the 
bowel  wall  revealed  fibrous  thickening,  and  sections  stained  for 
tubercle  bacilli  showed  them  to  be  present  in  large  numbers. 
There  was  no  ulceration  of  the  mucosa. 

C.  Briddon's  case*  was  that  of  a  man,  aged  34,  who  for  twelve 
years  had  been  suffering  from  constipation,  painful  defaecation, 
and  occasional  bleeding  and  tenesmus.  This  condition  had 
continued  with  exacerbations.  When  admitted  to  the  hospital 
he  had  six  to  eight  stools  daily,  which  contained  blood  and  mucus 
and  were  offensive.  Per  rectum  an  indurated  mass  could  be  felt. 
An  attempt  was  made  to  perform  a  left  inguinal  colotomy,  but 
the  colon  was  found  to  be  generally  infiltrated  and  bound  down, 
so  that  it  was  impossible  to  bring  any  portion  of  it  into  the 
abdominal  wound.  An  incision  was  made  on  the  right  side,  but 
it  was  found  that  the  whole  colon  was  similarly  infiltrated  and 
fixed.  The  small  intestine  was  normal,  and  enterotomy  was 
performed.  The  whole  colon  was  uniformly  thickened,  and  the 
thickening  terminated  in  a  hard  cartilaginous  mass  at  the  lower 
end  of  the  sigmoid  flexure.  The  colon  was  covered  with  pinkish- 
coloured  nodules,  looking  like  boiled  sago. 

In  J.  W.  Elliott's  case,t  the  patient,  a  woman,  had  suffered 
from  constipation  and  dyspepsia  for  twelve  years.  She  was 
admitted  into  the  hospital  for  a  supposed  tumour  in  the  rectum. 
On  opening  the  abdomen  it  was  discovered  that  the  whole  colon 

*  Trans.  New   York  Surg.  Soc.  May  23,  1894. 
f  New  York  Med.  Rec.  July  30,  1904. 


214  TUBERCULOSIS    OF 

from  the  rectum  to  the  splenic  flexure  was  a  soHd  tube  so  fixed 
that  it  could  hardly  be  moved.  A  right-sided  colotomy  was 
performed,  and  a  portion  of  the  mass  was  removed  for  examina- 
tion. It  was  found  to  consist  of  simple  inflammatory  tissue. 
Tubercle  bacilli  were  not  looked  for. 

Treatment. 

As  already  stated,  the  ulcerative  form  of  tubercle  of  the 
colon  usually  occurs  as  a  terminal  complication  in  advanced 
phthisis,  and  there  is  little  possibility  of  treating  it,  either  by 
medical  or  surgical  means.  Occasionally  it  may  happen  that 
surgical  treatment  is  called  for  to  deal  with  some  serious  com- 
plication which  has  resulted  from  the  ulceration,  such  as 
intractable  diarrhoea,  perforation  with  general  peritonitis,  and 
abscess.  Colotomy  can  seldom  be  of  any  use  in  treating  the 
diarrhoea,  for  the  csecum  is  almost  invariably  involved.  Appendi- 
costomy  might  be  of  value  in  controlling  the  diarrhoea,  by 
enabling  the  colon  to  be  washed  out  periodically,  and  it  has  the 
advantage  that  it  is  an  operation  of  so  little  severity  that  it 
could  easily  be  performed  in  cases  where  the  patient  is  seriously 
ill  with  phthisis,  without  grave  risk.  I  do  not,  however,  know 
of  any  case  in  which  it  has  been  done. 

The  Treatment  of  Hyperplastic  Tuberculosis  of  the 
Colon. — This  condition  is  so  rare  and  so  little  known,  that  it  is 
very  seldom  a  correct  diagnosis  is  made  previous  to  operation. 
The  abdomen  is  generally  opened  to  relieve  obstruction,  or  to 
explore  a  tumour,  supposed  to  be  malignant.  Even  when  the 
tumour  is  seen,  it  is  still  usually  thought  to  be  malignant  ;  and, 
indeed  the  diagnosis  cannot  be  made  without  cutting  open  the 
tumour,  or  microscoping  a  portion  of  it. 

This  being  the  case,  the  treatment  adopted  is  almost  invariably 
that  for  cancer.  It  is  therefore  a  fortunate  circumstance  that 
the  best  treatment  for  hyperplastic  tuberculosis  is  the  same, 
namely  excision  or  short-circuiting.  Unfortunately,  however, 
with  many  patients  the  tumour  is  not  excised,  because  the 
surgeon  believes  the  condition  to  be  one  of  malignant  disease, 
inoperable  because  of  adhesions  and  gland  involvement  ;  whereas, 
did  he  know  that  it  was  tubercle,  a  successful  excision  might  be 
performed. 

Operation  is  certainly  the  only  cure  for  this  form  of  tuberculosis 
of  the  colon,  and  medical  treatment  cannot  be  expected  to  do 


THE    COLON 


215 


any  good,  though  it  may  be  useful  after  operation  in  preventing 
further  tuberculous  mischief. 

Of  my  collected  series  of  100  cases,  all  but  7  were  operated 
upon,  the  methods  of  procedure  being  as  follows  : — 


Operation. 

No.  OF  Cases. 

Recovered. 

47 
13 

I 
I 

Died. 

16 
3 

2 

Mortality 

PER    CF.NT. 

Resection 
Short-circuiting 
Exclusion   with   colo- 

tomy 
Exclusion  with  lateral 

anastomosis 

63 
16 

7 
3 

25-4 

18-7 

85 
66 

Totals 

89 

62 

27 

In  addition  to  the  above,  exploratory  laparotomy  was  per- 
formed in  four  instances.  In  some  of  the  cases  most  complicated 
operations  were  done,  live  and  even  six  being  performed  on 
the  same  case  at  different  times. 

It  will  be  seen  that  the  lowest  operation  mortality  was  obtained 
by  short-circuiting  the  tumour.  This  is,  however,  not  so  satis- 
factory as  resection,  as  it  leaves  a  source  of  infection  behind. 
In  several  cases  the  tumour  diminished  in  size,  and  in  some 
it  disappeared  after  it  had  been  short-circuited.  In  four, 
however,  a  faecal  fistula  was  left  communicating  with  the 
tumour  ;  in  two,  the  patient  was  only  slightly  improved  by 
the  operation  ;  and  in  another  he  died  soon  afterwards  from 
phthisis.  Short-circuiting  is  probably  the  best  operation  when 
resection  of  the  tumour  would  be  attended  by  considerable  risk  ; 
but  these  cases  show  that  resection  is  a  much  preferable  procedure. 

There  are  seven  cases  in  which,  after  resection,  the  ends  of 
the  bowel  were  brought  out.  In  four  of  these  the  patient  had  a 
permanent  faecal  fistula,  which  could  not  be  closed  in  spite  of 
secondary  operations.  Resection  of  the  tumour  is  certainly  the 
ideal  method  for  this  condition,  and  the  operation-mortality  is 
not  much  higher  than  that  for  short-circuiting.  It  is  certain 
that  this  mortality  of  25  per  cent  can  be  considerably  lowered  by 
not  performing  immediate  resection  and  anastomosis  where 
there  is  obstruction,  or  the  bowel  above  the  tumour  cannot  be 
emptied  previous  to  operation. 


2l6 


TUBERCULOSIS    OF 


The  following  table  shows  the  methods  adopted  in  dealing 
Avith  the  ends  of  the  bowel  after  resection  : — 


Cases. 

Deaths. 

Mortality 

PliR   CENT. 

Immediate  end-to  end 

anastomosis            .  . 

39 

7 

17 

Closure    of    ends    and 

lateral    anastomosis 

or  implantation     .  . 

Preliminary  colotomy 

performed    or    ends 

brought    out     after 

i8 

3 

j6 

excision 

,  9 

3 

33 

One  patient  was  well 

One 

One 

One 

Two  patients  were 

One    patient    was 

One 

One  , ,        died 


of 


In  three  cases  lateral  anastomosis  was  performed  first,  and  the 
tumour  resected  later.  In  twelve,  where  the  stricture  was 
resected,  the  subsequent  history  was  traced  for  a  year  or  more 
after  operation  :- 

1  year  later. 
1 1  years  later. 

2  years  later. 

3  years  later. 

4  years  later. 

5  years  later. ' 
7  years  later. 

general    tuberculosis    one    year    after 
operation, 
tuberculosis  several  years  later, 
phthisis  two   years,   and   another  three 
years  after  operation. 
One  remained  well  for  three  years,  then  a  fistula  formed  in  the 
operation  scar,  and  in  an  attempt  to  close  it  the  patient  died. 

When  the  tumour  is  in  the  sigmoid  flexure,  colotomy  to  relieve 
the  obstruction  and  give  rest  to  the  tumour  is  certainly  the 
correct  treatment  ;    and  later,   if  feasible,   it  can   be   excised 
Contra-indications  to  operation  are  : — 

1.  Extensive  pulmonary  tuberculosis,  with  high  temperature. 

2.  Marked  albuminuria. 

3.  Severe  diarrhoea,  showing  the  presence  of  extensive  ulcera- 
tion. 


One 
One 


THE    COLON  217 

After  operation,  the  patient  should  be  put  under  medical 
treatment  and  carefully  watched  to  prevent  further  tuberculous 
trouble,  in  the  same  way  as  w"0uld  be  done  in  a  case  of  pulmonary 
tubercle. 

REFERENCES. 

F.  S.  KiDD. — Lancet,  Jan.  5,  1907. 
Crowder. — Amer.  Jour.  Med.  Sci.   1900,  638. 
CoNRATH. — Beitrage  zur  klin.  Chir.   1898,  21. 
Reclus. — Bull.  Med.  1893,  587. 
Page. — Lancet,  1897,  ii.  10. 
Lediard. — Lancet,  1898,  ii.  408. 
Bernay. — These  Lyon,  1898. 
ROLLESTON. — Tvans.  Path.  Sac.  1S90.  xl. 


2l8 


Chapter  XV. 

CHROXIC    coy  ST  IP  AT  lOX   AXD   F.ECAL 
IMPACTION. 

CHRONIC     CONSTIPATION. 

Although  it  is  usual  to  speak  of  chronic  constipation  as  a 
disease,  it  is  nevertheless  onh-  a  s}TTiptom  conunon  to  a  great 
number  of  totalh"  distinct  and  separate  affections.  Constipation 
results  from  the  intestinal  contents  being  unduly  delayed  in 
their  passage  along  the  aUmentary  canal.  This  may  occur  in 
any  part  of  it,  but  is  most  commonly  found  in  the  large  bowel, 
and  may  result  from  a  great  variety-  of  causes.  It  is  not  possible 
in  these  da\-5  to  consider  constipation  as  a  distinct  maladj-, 
and  the  first  essential  alwa}^^  is  to  ascertain  the  cause  for  the 
condition.  Chronic  constipation,  hke  many  other  complaints  of 
the  present  daj-,  is  in  most  cases  a  result  of  modem  civilized 
Hfe.  Among  native  races  and  wild  animals  it  is  practical!}^ 
unknown,  but  is  all  too  common  in  civilized  communities,  and, 
indeed,  forms  one  of  the  most  frequent  disorders  of  our  great 
cities.  Modem  methods  of  dietary-  and  the  sedentary  character 
of  our  dailv  Hfe  are  largely  responsible  for  the  tendenc\-  to 
constipation  which  is  so  prevalent.  It  is  one  of  the  penalties 
we  pay  for  the  comparativelj^  small  use  we  make  of  our  colons. 

Dr.  Hertz's  recent  researches,  in  which  patients  with  severe 
constipation  were  examined  by  the  X  rays  after  a  bismuth 
meal,  have  clearly  proved  that  in  most  severe  chronic  cases 
the  delav  occurs  in  the  lower  part  of  the  colon,  and  chiefly  in 
the  sigmoid  flexure.  This  is  the  natural  receptacle  for  the 
faeces  previous  to  dejection.  The  rectum,  being  purely  an 
expelling  organ,  is  empty  in  normal  individuals  except  just 
previous  to  and  during  the  act  of  defsecation.  Occasionally, 
constipation  may  result  from  the  rectum  not  acting  properly, 
as  in  chronic  nerve  lesions  of  the  spinal  cord,  but  this  is  com- 
paratively rare. 

Being  only  a  sMnptom,  constipation  can  have  no  distinctive; 


CHRONIC    CONSTIPATION  219 

pathology,  and  its  causes  form  a  large  part  of  the  subject  matter 

of  this  book,  and  will  be  found  scattered  throughout  its  pages. 

It  is  obvious  that  there  are  two  distinct  kinds  of  constipation  : 

1.  That  in  which  the  peristaltic  power  of  the  colon  is  normal, 
but  the  passage  of  faecal  material  is  delayed  by  the  presence 
of  some  obstruction  in  the  bowel ;  and 

2.  That  in  which  there  is  no  obstruction,  but  the  peristaltic 
and  expulsive  power  is  deficient. 

The  first  is  often  called  obstructive  and  the  second  atonic 
constipation. 

There  is  a  third  factor,  which  is  often  important,  though  it 
is  not  by  itself  a  frequent  cause  of  constipation.  This  is  the 
consistency  of  the  faecal  material. 

The  longer  fscal  material  is  delayed  in  its  passage  along  the 
colon,  the  harder  will  it  become,  owing  to  the  extraction  of 
water  by  the  bowel  walls  ;  and  the  harder  it  becomes  the  less 
easily  will  it  be  passed  along  by  peristalsis,  so  that  a  vicious 
circle  is  soon  established.  The  consistency  of  the  faeces,  there- 
fore, is  often  an  important  factor  both  in  obstructive  and  atonic 
constipation.  An  individual  should  not  be  considered  as 
suffering  from  constipation  simply  because  there  is  not  an 
action  of  the  bowels  daily.  Many  persons  only  have  such  an 
action  three  or  four  times  a  week,  and  yet  remain  in  perfect 
health  ;  while  others  again  have  a  normal  action  twice  daily. 
Constipation  is  only  present  when  the  bowels  act  with  no 
regularity,  or  only  as  the  result  of  aperients. 

Constipation  is  chiefly  of  importance  because  of  the  secondary 
symptoms  to  which  it  gives  rise.  These  symptoms  are  very 
numerous,  such  as  headache,  dullness,  discomfort  in  the 
abdomen,  backache,  furred  tongue,  etc.,  but  the  most  important 
result  of  severe  chronic  constipation  is  the  condition  often  called 
auto-intoxication.  When  the  contents  of  the  colon  are  unduly 
delayed  in  their  passage  to  the  anus,  and  remain  long  retained 
within  the  body,  certain  alterations  take  place.  Chemical 
changes  occur  in  the  faecal  material,  and  many  of  the  waste 
products  of  digestion  become  still  further  spht  up  into  poisonous 
substances  or  toxins.  Under  normal  circumstances  there 
would  not  be  time  for  the  formation  of  poisonous  by-products 
before  the  faeces  are  discharged  from  the  body  ;  but  in  chronic 
constipation  considerable  quantities  of  these  may  form  while 
the  faeces  are  still  in  the  colon,  and  may  then  be  absorbed  by 


220  CHRONIC    CONSTIPATION 

the  bowel-wall,  and  find  their  way  into  the  blood-stream.  The 
patient  in  fact  is  slowly  poisoned  by  toxins  formed  within  his 
own  colon. 

We  have  good  evidence  of  the  extremely  poisonous  nature 
of  these  toxins  in  cases  of  intestinal  obstruction.  Here,  when 
death  occurs,  it  is  more  often  due  to  a  profound  toxaemia  from 
the  poisons  generated  within  the  obstructed  bowel,  than  from 
the  obstruction  itself. 

The  toxsemia  in  chronic  constipation  is  never  so  serious  or 
profound  as  in  intestinal  obstruction,  because  the  poisoning 
occurs  more  slowly,  and  the  bowel-wall  being  undamaged, 
absorption  does  not  occur  so  readily.  It  often,  nevertheless, 
produces  after  a  time  very  serious  consequences.  The  patient 
becomes  lethargic  and  listless.  The  appetite  is  poor,  and  there 
is  a  general  feeling  of  not  being  well.  The  skin,  instead  of 
looking  healthy,  becomes  of  a  greyish  or  earthy  colour.  The  skin 
smeUs  ;  the  tongue  is  coated  ;  and  frequently  much  of  the  sub- 
cutaneous fat  disappears.  There  is  generally  a  chronic  headache, 
and  sometimes  severe  neuralgia  and  even  more  serious  mental 
S5nnptoms  have  occurred.  The  appearance  of  patients  suffering 
from  chronic  auto-intoxication  is  often  quite  characteristic, 
the  listless  appearance  and  the  colour  of  the  skin  being  alone 
sufficient  to  identify  them  as  the  subjects  of  chonic  constipation. 
By  no  means  all  sufferers  from  constipation,  however,  are  the 
subjects  of  auto-intoxication.  We  not  infrequently  meet  with 
individuals  whose  bowels  act  most  irregularly  and  at  long  inter- 
vals, without  any  apparent  ill  effects.  I  have  seen  at  least 
two  patients,  whose  bowels  had  not  acted  for  three  weeks  or 
a  month,  who  presented  no  signs  of  auto-intoxication,  and  we 
must  assume  here  either  that  the  poisons  are  not  absorbed 
or    that  the  patient  is  immune  to  their  effects. 

Atonic  constipation  results  from  the  muscular  action  of  the 
bowel-wall  being  deficient.  This  is  apparently  not  due  to  anj^ 
reduction  in  the  number  of  the  unstriped  muscle  fibres,  but  to 
the  absence  of  the  normal  stimuH.  Peristalsis  is  normally  a 
reflex  action  set  up  by  the  presence  of  material  within  the 
bowel ;  in  atonic  constipation  this  reflex  becomes  sluggish. 
Most  often  this  constipation  is  a  secondary  condition  resulting 
from  irregular  habits  in  going  to  stool,  improper  diet,  viscero- 
ptosis, or  some  other  general  trouble.  It  may  be  associated 
with  loss  of  tone  in  the  abdominal  muscles,  and  this  becomes 


CHRONIC    CONSTIPATION  221 

important,  since  it  is  upon  these  muscles  that  the  expulsion 
of  the  faeces  chiefly  depends. 

Among  other  causes  of  atonic  constipation  must  be  mentioned 
disease  of  the  central  nervous  system,  such  as  tabes  dorsalis 
and  disseminated  sclerosis  ;  neurasthenia  is  often  included, 
but  it  seems  at  least  as  probable  that  it  is  a  result. 

Treatment. 

The  treatment  of  chronic  constipation  obviously  depends 
upon  the  conditions  underlying  it,  and  the  correct  method  is 
to  ascertain  these  causes  and  to  correct  or  remove  them.  When 
due  to  obstruction,  such  as  a  chronic  volvulus,  adhesions,  a 
tumour  or  stricture,  operation  is  clearly  indicated.  For  the 
treatment  of  obstructive  constipation,  the  reader  is  referred  to 
other  portions  of  this  book. 

In  atonic  constipation,  treatment  should  be  directed  to 
improving  the  tone  of  the  bowel-wall  and  increasing  the  normal 
stimulus  to  peristalsis.  For  this  purpose  a  course  of  massage, 
combined,  if  possible,  with  suitable  electrical  treatment,  is 
usually  most  efficacious  if  properly  carried  out.  Strychnine 
or  nux  vomica  are  most  useful  in  increasing  the  peristaltic 
movements,  and  their  action  is  often  enhanced  by  the  addition 
of  belladonna.  At  first  these  drugs  should  be  combined  with 
a  small  amount  of  some  mild  aperient,  and  later,  when  they 
have  begun  to  do  good,  should  be  used  alone.  I  have  found 
the  following  pill  most  useful  in  these  cases  : — 

B 

Ext.  Colocynth.  co.  .  .  .  .  .  .  grs.  ix 

Ext.  Cascarse  .  .  .  .  .  .  grs.  x 

Ext.  Belladonnae  .  .  .  .  .  .  grs.  iv 

Ext.  Nucis  Vomicae  .  .  .  .  .  .  grs.  iv 

Mitte  pil.  xii. — One  or  two  at  bedtime  each  night. 

The  results  of  treatment  in  cases  of  chronic  constipation  are 
far  better  where  aperients  are  not  used.  They  are  an  easy 
means  of  getting  the  bowels  to  act ;  but  they  do  not  remove 
the  cause  of  the  condition,  and,  as  a  rule,  ultimately  result  in 
making  it  worse,  or  in  the  patient  being  condemned  to  continue 
their  use. 

Occasionally,  where  there  is  a  gouty  element,  the  use  of  some 
aperient  water  containing  small  doses  of  magnesia  and  lithia 


222  CHRONIC    CONSTIPATION 

is  very  beneficial,  but  with  a  few  exceptions  aperients  are  best 
avoided. 

Enemata  are  in  many  cases  much  to  be  preferred  to  the  use 
of  aperients,  and  especially  where  for  long  periods  some  artificial 
aid  has  to  be  used  to  ensure  the  bowels  acting. 

There  are  frequent  instances  where  the  abnormal  solidity 
of  the  fseces  is  a  most  important  factor  in  maintaining  the 
condition  ;  here  it  will  be  found  that  if  steps  are  taken  to 
prevent  the  faeces  from  becoming  solid  a  marked  improvement 
will  quickly  result.  In  a  few  cases  merely  increasing  the 
amount  of  fluids  drunk  during  the  day  will  be  sufficient ;  but 
as  water  is  readily  absorbed  by  the  colon  wall  this  will  only 
be  of  service  where  the  patient  has  been  in  the  habit  of  taking 
less  fluid  than  his  tissues  require,  and  in  whom,  therefore,  the 
deficiency  has  been  made  up  from  the  faeces. 

Fats,  which  are  liquid  at  body  temperature,  will  prevent  the 
faeces  from  solidifying,  and  as  only  a  very  limited  quantity  of 
fat  can  be  absorbed  by  the  alimentary  tract,  it  is  quite  easy 
to  attain  the  desired  result  by  giving  an  excess  of  fat  in  the 
diet.  The  addition  per  diem  of  two  ounces  of  thick  cream  to 
the  patient's  diet  will  generally  render  the  stools  quite  soft, 
and  it  is  easy  to  ascertain  by  experiment  the  exact  quantity 
of  fat  required.  Salads  with  oil,  milk,  bacon,  and  other  forms 
of  diet  which  contain  fat,  will  readily  suggest  themselves. 
Some  patients,  however,  are  unable  to  take  an  excess  of  fat 
without  getting  dyspepsia. 

Mineral  fats  have  not  this  objection  ;  they  are  not  absorbed 
at  all  in  their  passage  through  the  ahmentary  canal,  but  pass 
out  as  they  went  in.  Petroleum  in  some  form  can  be  given 
for  any  length  of  time  without  causing  harmful  results,  and  by 
administering  suitable  quantities  of  it  any  desirable  consistency 
of  the  faeces  can  be  obtained. 

Several  different  forms  of  emulsion  containing  petroleum 
have  recently  been  placed  on  the  market,  and  have  been  much 
lauded  in  the  treatment  of  constipation  and  allied  conditions, 
but  emulsions  are  not  so  efficacious  as  pure  petroleum,  and 
their  only  advantage  is  that  they  are  slightly  less  greasy 
to  the  taste.  Lenital  is  the  best  preparation,  and  should 
be  given  by  the  mouth  in  teaspoonful  doses.  As  a  rule  a 
teaspoonful  of  Lenital  three  times  a  day  will  very  quickly 
render  the  stools  quite  soft  or  even  semi-liquid.     If  not,  the 


CHRONIC    CONSTIPATION  223 

dose  should  be  increased  until  this  result  is  obtained.  It  is 
rather  greasy,  but  otherwise  tasteless  except  for  a  ilavouring 
of  peppermint,  and  I  have  found  that  patients  do  not  object  to 
it  or  find  it  unpleasant  to  take.  I  have  had  a  number  of  cases 
of  severe  chronic  constipation  of  the  atonic  type  which  have 
entirely  recovered  by  the  employment  of  this  simple  remedy 
alone.  Even  some  cases  of  obstructive  constipation  are  very 
much  improved  by  rendering  the  faeces  soft,  and  as  an  adjunct 
to  massage  and  electricity  it  is  most  useful  in  cases  of  constipation 
due  to  adhesions.  I  have  had  several  patients  who  for  years 
had  been  in  the  habit  of  taking  aperients  daily,  and  whose 
bowels  only  acted  as  a  result  of  medicine,  who  have  been  able 
entirely  to  stop  the  use  of  aperients  when  they  began  to  take 
petroleum  in  this  form. 

Massage. — This  is  one  of  the  best  methods  of  treating  atonic 
constipation,  and  cases  where  there  are  adhesions  interfering 
with  the  movements  of  the  bowel.  It  is  also  useful  after 
operations  undertaken  for  the  cure  of  obstructive  constipation. 
For  the  success  of  this  treatment  it  is  essential  that  a  skilled 
masseur  or  masseuse  be  employed  ;  partially  trained  persons 
are  of  little  use.  Before  commencing  the  massage  the  patient 
should  be  put  on  a  fuU  diet  containing  plenty  of  cellulose  and  a 
sufficient  quantity  of  fat,  or  its  substitute  petroleum,  to  ensure 
the  faeces  being  unformed. 

If  possible,  it  is  better  to  commence  with  massage  for  ten 
minutes  twice  a  day  about  two  or  three  hours  after  meals.  This 
is  very  much  better  than  one  treatment  of  longer  duration,  and 
is  more  easily  borne  by  the  patient.  The  massage  must  at  first 
be  very  gentle,  and  only  slowly  increased  as  the  patient  becomes 
accustomed  to  it.  Very  vigorous  massage  is  a  mistake,  and 
does  far  less  good  than  hght  massage.  We  should  aim  at 
moving  on  the  contents  of  the  colon  by  stimulating  peristalsis 
and  by  direct  kneading  of  the  colon  in  a  direction  towards  the 
anus.  Special  attention  should  also  be  paid  to  the  development 
of  the  abdominal  muscles,  and  for  this  purpose  the  exercises 
described  below  are  most  useful,  and  may  with  advantage  be 
combined  with  the  massage.  After  a  few  days,  if  the  massage  is 
well  borne  and  does  not  cause  discomfort,  each  treatment  may 
slowly  increased  up  to  twenty  minutes  twice  daily.  There  is 
little  to  be  gained  by  continuing  it  for  more  than  twenty 
minutes    at    one   time.     As    soon    as  massage  is    commenced, 


224  CHRONIC    CONSTIPATION 

all  aperients  should  be  stopped,  if  they  are  being  taken.  Usually 
the  bowels  at  once  commence  to  act  naturally  ;  should  they 
not  do  so,  enemata  of  soft  soap  and  water  should  be  used.  The 
massage  should  be  continued  daily  for  at  least  three  weeks,  and 
if  possible  longer  ;  after  this,  for  two  or  three  times  a  week  for 
another  six  weeks  or  two  months.  Patients  often  object  to 
the  inconvenience  of  daily  massage  ;  but  I  have  found  it  most 
important,  unless  only  temporary  benefit  is  to  result  from  the 
treatment. 

When  the  patient  has  sufficiently  improved  as  the  result 
of  the  treatment,  and  the  bowels  are  acting  regularly,  he  should 
be  told  to  take  daily  exercise,  preferably  walking  or  riding  ;  and 
to  make  a  habit  of  relieving  the  bov/els  at  the  same  time  each 
day.  Cannon  balls  covered  with  wash-leather,  and  various 
forms  of  rollers,  are  often  used  in  the  treatment  of  constipation 
by  massage,  but  if  a  skilled  masseur  is  obtainable  artificial  aids 
are  unnecessary. 

Vibration,  if  proper  apparatus  is  used,  is  also  a  useful  aid  to 
massage  in  these  cases. 

Exercises  for  Developing  the  Abdominal  Muscles. — 
The  following  exercises  should  be  carried  out  daily,  at  first 
under  the  supervision  of  the  masseur,  and  later  by  the  patient 
for  himself.  They  should  be  done  in  succession,  and  continued 
about  fifteen  minutes,  but  never  for  long  enough  to  cause  fatigue. 
Each  movement  should  be  done  slowly  and  deliberately.  When 
the  patient  is  also  having  massage,  it  should  follow  the  exercises. 

Exercise  i. — The  patient  should  lie  flat  on  his  back  on  a  firm 
bed  or  upon  the  floor,  and  with  his  hands  by  his  sides.  The 
knees  should  be  drawn  up  to  the  chest,  then  straightened  out  at 
right  angles  with  the  trunk.  With  the  knees  kept  stiff,  the  legs 
should  then  be  slowly  lowered  until  they  again  touch  the  bed. 

Exercise  2. — With  the  patient  lying  as  before,  the  right  leg, 
with  the  knee  kept  stiff,  should  be  slowly  raised  till  it  is  at  right 
angles  with  the  body.  It  should  then  be  slowly  lowered 
again,  still  with  the  knee  stiff,  stopping  for  a  few  seconds  at 
different  angles  with  the  trunk.  Two  or  three  stops  should  be 
made  before  the  leg  again  rests  op  the  bed. 

The  same  exercise  should  be  carried  out  with  the  left  leg. 

Exercise  3. — The  patient  should  lie  on  the  floor  with  his  hands 
by  his  sides.  Then,  while  his  legs  are  held  down,  he  should 
slowly  raise  himself  into  a  sitting  position  without  using  his  hands. 


CHRONIC    CONSTIPATION  225 

The  body  should  then  be  twisted  round,  first  in  one  direction 
and  then  in  the  other  ;  he  should  then  slowly  lie  down  again. 

Exercise  4. — The  patient  stands  up  and  slowly  raises  first  one 
leg  and  then  the  other.  Each  knee  should  be  brought  up  until 
it  touches  the  chest. 

Exercise  5. — The  patient  stands  with  his  hands  on  bis  hips  and 
slowly  rotates  the  body,  first  in  one  direction  and  then  in  the  other. 

Exercise  6. — Repeat  Exercise  2,  but  with  both  feet  together 
instead  of  alternately.  This  and  Exercise  7  should  not  be  used 
at  first,  but  may  usefully  supplement  the  foregoing  exercises 
at  the  end  of  a  week  or  ten  days. 

Exercise  7. — The  patient  sits  on  the  floor,  and  the  feet  are  held 
down.  He  then  slowly  sways  himself  backwards  and  forwards 
from  the  hips. 

Exercise  8. — (This  is  to  develop  the  gluteal  muscles).  With 
the  hands  on  the  hips,  the  patient  squats  down  on  his  heels ; 
then  slowly  raises  himself  into  the  standing  position,  and  again 
slowly  lowers  himself  until  he  is  sitting  on  his  heels.  This 
should  be  repeated  two  or  three  times. 

Electrical  Treatment. — ^There  are  many  different  kinds 
of  electrical  treatment  used  for  chronic  constipation  ;  some 
are  quite  useless,  as  they  do  not  cause  contraction  of  the 
unstriped  muscle  of  the  bowel-wall.  This  especially  appHes 
to  small  galvanic  and  faradic  apparatus  which  can  be 
obtained  for  a  few^  pounds  ;  such  apparatus  are  quite  valueless 
for  this  purpose,  and  if  benefit  does  occur  after  their  use,  it  is 
due  to  suggestion  rather  than  to  electricity. 

One  of  the  forms  which  seems  to  do  most  good  in  atonic  cases 
is  the  application  to  the  abdomen  of  a  continuous  current  with 
quick  reversals,  one  reversal  each  minute.  The  pads  should 
be  large,  and  applied  one  on  each  side  of  the  abdomen.  A 
cushion  must  be  placed  between  the  knees  to  prevent  their 
knocking  together  and  becoming  bruised.  The  current  should 
go  up  to  100  milhamperes.  Each  treatment  should  last  about 
ten  minutes,  and  not  be  repeated  oftener  than  thrice  a  week. 

Another  very  useful  form  of  electricity  is  the  three-phase 
sinusoidal  current.  The  patient  lies  on  a  couch  with  one  large 
pad  in  the  middle  of  the  back,  and  two  smaller  ones,  one  on  each 
side  of  the  abdomen.  The  current  should  not  be  strong  enough 
to  cause  any  discomfort.  The  treatment  should  be  continued 
for  about  fifteen  or  twenty  minutes,  care  being  taken  to  switch 

15 


226  CHRONIC    CONSTIPATION 

off  the  current  before  putting  on  or  removing  the  pads,  and 
not  to  disturb  the  pads  while  the  current  is  passing. 

The  high-frequency  current  is  also  useful  if  properly  applied. 
A  good  apparatus  is  essential,  and  a  very  high  frequency  current 
should  be  used,  with  a  spark-gap  of  not  less  than  one  and  a  half 
inches.  The  patient  should  lie  on  a  couch  which  is  not  insulated, 
and  should  be  in  good  contact  with  the  electrode  ;  that  is  to 
say,  he  should  either  firmly  grasp  a  metal  bar  electrode,  or  have 
one  resting  firmly  on  the  abdomen.  The  administration  of  the 
high-frequenc3;'  current  by  means  of  loose  and  moving  contacts, 
such  as  brushes  or  glass  electrodes  which  are  moved  about, 
causes  pain,  and  serves,  I  believe,  no  good  purpose. 

The  current  should  alwa3^s  be  switched  on  after  the  patient 
is  in  contact  with  the  electrode,  and  off  before  he  has  released  it. 
If  properly  administered  it  should  cause  no  sensation  while  pass- 
ing.    It  should  be  administered  every  day  for  fifteen  minutes. 

Hydrotherapy  in  its  various  forms  is  now  very  popular 
for  the  treatment  of  chronic  constipation,  especially  at  the 
English  and  Continental  spas.  Personally,  I  have  not  seen  as 
good  results  from  it  as  from  massage  and  electricity. 

The  so-called  Plombieres  treatment,  or  lavage  of  the  bowel, 
is  not  suitable  in  atonic  constipation,  as  it  dilates  an  already 
weakened  and  dilated  colon,  and,  I  believe,  tends  to  increase 
and  accentuate  the  atony  of  the  bowxl-wall  rather  than  to 
improve  it.  It  undoubtedly  does  temporary.'  good  b\'  clearing 
out  the  colon  and  washing  away  scybala,  but  the  improvement 
is  seldom  permanent,  while  some  cases  are  certainly  rendered 
worse  b}.'  it.  Plombieres  treatment  consists  of  the  daily  adminis- 
tration of  large  enemata,  containing  a  slight  quantity  of  some 
salt,  by  means  of  a  long  tube.  It  is  supposed  that  the  long 
tube  passes  into  the  colon,  but,  as  I  have  already  pointed  out, 
this  is  not  the  case  ;  the  tube  in  most  cases  remains  curled  up 
in  the  rectum.  Any  good  results  obtainable  from  Plombieres 
treatment  can  be  equally  realized  by  the  use  of  ordinary  soap 
and  water  enemata  when  properly  administered.  ^ 

Operative  Treatment. — Operations  which  are  performed 
for  chronic  constipation  without  reference  to  the  underlying 
pathological  cause  cannot  be  considered  as  satisfactory  or 
scientific  procedures  ;  before  advising  operation  there  should 
be  a  clear  understanding  of  the  pathological  conditions  at 
work,  and  the  manner  in  which  they  are  to  be  benefited. 


CHRONIC    CONSTIPATION  227 

In  most  cases  of  obstructive  constipation,  surgery  affords 
the  only  satisfactory  means  of  dealing  with  it  or  of  curing  it. 
The  various  methods  employed  will  be  found  elsewhere  in  this 
book. 

There  are  certain  cases  of  atonic  constipation  in  which 
operation  is  called  for  ;  but  these  are  exceptional,  and  in  all 
of  them,  if  a  thorough  course  of  non-operative  treatment  has 
not  already  been  tried,  it  should  first  be  prescribed. 

The  cases  which  require  operation  are  those  in  which  the 
patient  is  getting  seriously  ill  from  auto-intoxication,  and  the 
bowels  cannot  be  made  to  act  regularly  either  by  enemata, 
aperients,  or  massage.  Cases  are  occasionally  met  with  in 
which  nothing  seems  to  do  good,  and  patient  and  doctor 
are  in  despair.  The  patient  has  spent  months  at  spas  without 
any  permanent  relief ;  massage  only  causes  discomfort,  and 
only  the  most  drastic  aperients,  and  those  in  full  doses,  will 
relieve  the  bowels.  The  patient  is  always  ill,  and  can  think  of 
nothing  else  but  the  condition  of  the  bowels,  and  is  rapidly 
becoming  a  chronic  invalid. 

Here  an  operation  is  certainly  the  best  treatment,  and  is  quite 
justified.     Three  methods  have  been  advised,  viz.  : — 

1.  To  perform  appendicosiomv ,  in  order  that  the  colon  may 
be  washed  out  daily,  and  the  accumulation  of  faecal  material 
within  it  thereby  prevented. 

2.  To  short-circuit  the  colcn  by  performing  ileo-sigmoidostomy. 

3.  To  resect  the  entire  colon. 

Appendicostomy. — It  is  obvious  that  it  is  not  the  colon 
which  causes  auto-intoxication  so  much  as  the  material  which 
is  retained  in  it.  If  we  can  prevent  this  retention,  we  shall  be 
able  to  stop  the  chronic  poisoning  from  which  the  patient 
suffers.  If  an  appendicostomy  is  performed,  the  patient  is 
able  to  wash  out  the  colon  daily  and  so  prevent  accumulation. 
The  results  have  in  most  cases  been  extremely  encouraging, 
and  the  daily  irrigation  has  caused  rapid  and  marked  improve- 
ment in  the  patient's  general  condition.  Further,  in  several 
cases  after  irrigation  has  been  carried  out  continuously  for  some 
time,  there  have  been  signs  that  the  colon  was  recovering  its 
lost  functions,  the  bowels  having  begun  to  act  regularly  without 
the  irrigation.  Appendicostomy  has  an  advantage  over  the 
other  two  operations  mentioned,  in  that  it  is  practically  un- 
attended by  any  risk  to  life,  and  that  it  does  not  in  any  way 


228  CHRONIC    CONSTIPATION 

mutilate  the  patient  or  leave  a  condition  which  may  at  some 
later  period  cause  trouble. 

Ileo-sigmoidostomY. — In  October,  1900,  Mr.  Mansell  MouUin 
published  a  case  in  which  he  had  performed  this  operation  for 
chronic  constipation,  and  Mr.  Arbuthnot  Lane  published  a 
paper  advocating  it  in  1904. 

Mr.  Lane,  who  has  performed  a  number  of  these  operations, 
found  that  the  results  were  satisfactory,  but  that  the  partially 
excluded  colon  was  a  source  of  danger,  and  this  has  led  him  to 
advocate  complete  resection  of  the  colon  as  being  preferable. 

Resection  of  the  Colon. — This  has  been  often  performed 
by  Mr.  Lane,  the  ileum  being  implanted  into  the  rectum  or 
sigmoid  flexure. 

Frequently  a  very  marked  improvement  in  the  patient's 
general  condition  resulted  from  the  removal  of  the  colon.  The 
operation  is,  however,  a  severe  one,  and  the  improvement  is 
not  always  permanent.  Lane  has  reported  28  cases  of  excision 
of  the  colon  for  this  condition  ;  of  these  7  died  and  21  recovered. 
This  is  a  mortality  of  33  per  cent. 

Sufficient  time  has  not  yet  elapsed  to  enable  us  to  determine 
the  ultimate  results.  The  mortality  in  Lane's  cases  is  sur- 
prisingly low  for  so  serious  an  operation  ;  but  it  seems  very 
doubtful  whether  a  method  followed  by  so  high  a  mortality  as 
33  per  cent  is  justifiable,  especially  when  appendicostomy 
seems  to  be  attended  with  equally  good  results  in  similar  cases. 
It  is  certainly  advisable  to  do  appendicostomy  first,  and  only 
resort  to  resection  if  this  fails  to  relieve  the  symptoms. 

F^CAL     IMPACTION. 

Occasionally  a  fsecal  mass  or  enterolith  forms  in  the  colon, 
and  causes  a  condition  of  chronic,  or  in  a  few  cases  even  acute, 
obstruction.  The  commonest  situation  for  such  fascal  masses 
is  in  the  rectal  ampulla,  but  they  may  also  be  met  with  in  the 
caecum,  the  sigmoid  flexure,  and  at  the  splenic  angle. 

Out  of  the  46  cases  collected  by  Gant,  the  situation  of  the 
calculus  or  mass  was  as  follows  : — 

Cases. 
Rectum  .  .  .  .  .  .  35 

Sigmoid  ...  .  .  .  .  5 

Descending  Colon  .  .  .  .  i 

Transverse  Colon 
Caecum 


F^GAL    IMPACTION  229 

They  are  not  infrequently  met  with  in  the  rectum  of  old  women 
the  subjects  of  chronic  constipation.  Under  such  circumstances 
thej^  are  about  the  size  of  an  orange  and  of  the  consistency  of 
concrete. 

Fffical  calculi  are  most  frequently  met  with  in  elderly  persons, 
but  are  not  confined  to  an^-  particular  age,  and  may  be  found 
even  in  children.  The  concretion  is  usually  single,  but  cases 
of  multiple  calcuH  have  been  recorded  in  which  as  many  as  38 
were  removed  from  the  same  patient. 

The  composition  varies  considerably.  They  may  consist 
of  anv  indigestible  material  which  has  been  swallowed,  such 
as  hair,  cotton  fibre,  and  cellulose.  The  majority,  however, 
are  composed  of  a  mixture  of  inspissated  faeces  and  inorganic 
salts.  The  nucleus  is  generally  a  foreign  body,  such  as  a  fruit- 
stone. 

The  chemical  composition  of  these  stercoliths,  apart  from 
the  foreign  bodies  of  which  they  may  be  composed,  is  variable  ; 
but  the  usual  ingredients  include  magnesium  and  ammonium 
phosphate,  potassium  sulphate,  sodium  carbonate,  calcium 
phosphate,  and  cholesterin.  The  centre  is  usually  very  hard, 
and  white  or  colourless.  Outside  this  are  concentric  layers 
of  earthy  matter  of  varying  degrees  of  hardness. 

These  calcuU  are  often  of  considerable  size.  I  have  removed 
one  from  the  rectum  which  was  the  size  of  a  child's  head. 

Faecal  impaction  and  the  formation  of  enteroliths  is  never 
a  primary  condition ;  some  abnormality  of  the  colon  or  rectum, 
of  the  nature  of  obstruction  or  atony,  must  necessarily  be 
present.  The  most  distinctive  cases  of  faecal  impaction,  in 
which  the  mass  often  weighs  several  pounds,  are  those  curious 
instances  of  congenital  dilatation  and  hypertrophy  of  the  colon. 
(See  Chap.  IV.). 

Fffical  calculi  tend  to  set  up  inflammation  in  the  surrounding 
colon,  and  many  of  the  symptoms  they  cause  are  due  to  this 
fact.  Ulceration,  and  in  a  few  instances  perforation,  may 
occur. 

The  following  rare  case,  in  which  a  faecal  calculus  was  found 
in  the  splenic  flexure,  producing  obstruction,  w^as  recorded  by 
M.  Morestin. 

Case. — The  patient  was  a  woman,  aged  31,  who  had  suffered 
from  constipation  for  two  years.  Abdominal  pains  set  in  during 
gestation,    and  a  month  after  delivery  a  tumour  was  felt  in  the 


230  FvECAL    IMPACTION 

abdomen.  The  patient  became  ill,  with  symptoms  of  chronic 
obstruction,  which  were  only  temporarily  relieved  by  enemata.  On 
opening  the  abdomen  a  fa?cal  calculus  of  extreme  hardness  was 
found  in  the  splenic  angle  of  the  colon.  This  portion  of  the  bowel 
was  resected,  together  with  the  calculus,  and  the  colon  anastomosed 
end  to  end.  The  patient  recovered.  The  stone  required  a  hammer 
to  break  it,  and  consisted  of  concentric  laminae.  It  measured  7 
inches  in  its  longest  by  5!  inches  in  its  shortest  diameter,  and 
weighed  368  grams,  about  four-fifths  of  a  pound.  There  was  a 
stricture  from  old  ulceration  at  the  site  where  the  concretion  was 
impacted. 

Case. — A  case  was  recorded  by  M.  Pozzi  at  the  French  Congress 
of  Surgery  in  October,  igo8,  of  a  man  who  for  years  had  suffered 
from  an  abdominal  tumour  of  absolutely  wooden  consistency.  It 
extended  from  the  umbilicus  to  the  pelvis,  and  was  movable  only 
in  a  transverse  direction.  No  exact  diagnosis  had  been  made. 
M.  Pozzi  performed  laparotomy,  and  found  that  the  tumour  con- 
sisted of  the  lower  part  of  the  sigmoid  flexure,  in  which  was  a 
stercolith  of  stony  hardness.  The  intestine  was  divided  and  the 
mass  removed.  The  gut  was  subsequently  closed,  and  the  patient 
made  a  good  recovery. 

A  similar  case  is  recorded  by  Balfour  Marshall.*  : — 

Case. — The  patient  was  a  woman,  aged  46,  who  complained 
of  a  small  lump  in  the  abdomen,  to  which  she  attributed  her  sym- 
ptoms. The  chief  complaint  was  of  colicky  pains.  There  was  a 
history  of  constipation.  In  the  lower  right  quadrant  of  the  abdomen 
there  was  a  hard  ovoid  lump,  the  size  of  a  hen's  egg.  It  was  freely 
movable.  It  was  thought  to  be  either  a  solid  ovarian  tumour 
with  a  long  pedicle,  or  cancer  of  the  bowel-wall.  Laparotomy  was 
performed,  and  the  tumour  was  found  to  be  a  stercolith  in  the  caecum 
above  a  fibrous  stricture.  The  stricture  and  c^cum  were  incised 
and  the  mass  removed.  In  sewing  up  the  wound  in  the  caecum  the 
stitches  were  so  inserted  as  to  render  the  wound  transverse  instead 
of  longitudinal,  thereby  increasing  the  diameter  of  the  strictured 
area.     Recovery  was  uninterrupted. 

Symptoms. 

The  characteristic  sjmiptoms  of  fgecal  calculi  are  diarrhoea 
and  colic.  This  not  infrequently  leads  to  a  wrong  diagnosis,  as 
it  is  sometimes  supposed  that  constipation  should  result  from 
a  faecal   impaction   in    the   colon.     The   diarrhoea  is    spurious, 

*  Glasg.  Med.  Jour.  1907,  238. 


Fy^GAL    IMPACTION  231 

and  is  due  to  the  irritation  and  ulceration  set  up  by  the  cal- 
culus. If  the  concretion  is  in  the  rectum,  tenesmus  is  a 
prominent  feature.  After  a  time  blood  and  pus  may  make 
their  appearance  in  the  stools.  The  stools  themselves  are  thin, 
watery,  and  frequent,  but  small  in  quantity.  The  symptoms 
in  fact  are  those  of  ulcerative  colitis  rather  than  anything  else. 

In  faecal  impaction  not  due  to  a  calculus,  ulceration  is  less 
common,  and  constipation  is  the  rule,  accompanied  by  abdominal 
colic  and  sometimes  vomiting. 

A  careful  examination  both  of  the  rectum  and  abdomen  will 
generally  clear  up  the  diagnosis,  as  the  mass  can  be  felt.  If  it 
can  be  indented  the  diagnosis  is  clear,  but  where  a  hard  calculus 
is  present  in  som^e  part  of  the  colon  where  it  cannot  be  seen  by 
the  sigmoidoscope,  it  may  be  difficult  to  distinguish  the  condition 
from  cancer. 

Treatment. 

When  the  condition  can  be  diagnosed,  attempts  should  be 
made  to  soften  the  mass  by  means  of  large  oil  enemata,  and 
if  this  succeeds  the  mass  can  be  slowly  washed  out  by 
repeated  soap-and-water  enemata.  A  solution  of  hydrogen 
peroxide,  if  it  can  be  brought  into  contact  with  a  feecal  concretion,, 
will  readily  split  it  up  and  disintegrate  it.  As  the  peroxide 
soaks  into  the  mass,  bubbles  of  gas  form  in  its  substance  and 
break  it  up.  X^'hilc  this  is  a  very  effective  method,  it  is  not 
free  from  risk,  as  the  large  quantity  of  gas  formed  distends  the 
bowel  and  may  rupture  it,  especially  if  there  is  any  ulceration. 
If  a  free  exit  lor  the  gas  can  be  ensured,  however,  this  method 
of  breaking  up  the  calculus  may  be  tried. 

As  a  rule,  when  the  calculus  is  in  the  colon,  surgical  operation 
affords  the  onl}-  possible  means  of  dealing  v.'ith  it.  The  abdomen 
should  be  opened  and  the  portion  of  the  colon  containing  the 
calculus  brought  into  the  wound.  If  possible,  the  calculus 
should  be  pressed  up  into  a  healthy  portion  of  colon.  This 
should  then  be  incised  in  the  long  axis,  and  the  calculus  removed. 
Before  closing  the  incision  into  the  bowel  the  interior  should  be 
examined  for  a  stricture,  which  is  frequently  present,  and  if  this 
is  found  it  should  be  dealt  with  at  the  same  time. 

It  is  well  to  remember  that  faecal  impaction,  or  the  formation 
of  a  calculus,  does  not  occur  in  a  normal  colon,  and  that  the 
presence  of  one  of  these  conditions  indicates  some  abnormalitv 


232  F^GAL    IMPACTION 

of  the   bowel.     The  following  case  well  exemplifies  this  state- 
ment. 

Case. — The  patient  was  an  elderly  gentleman  who  for  some 
months  had  been  troubled  with  constipation,  to  which  he  was  not 
accustomed.  On  examination  of  the  abdomen,  his  doctor  discovered 
a  tumour  in  the  left  iliac  fossa,  and  asked  me  to  see  the  patient  with 
a  view  to  ascertaining  its  nature.  Before  I  saw  him  a  dose  of 
castor  oil  and  several  enemata  had  been  administered,  and  as  a 
result  the  tumour  had  disappeared.  An  attempt  to  examine  him 
w-ith  the  sigmoidoscope  failed,  as  the  bowel  was  still  loaded  with 
fseces.  We  came  to  the  conclusion  that  the  tumour  had  been  a 
fsecal  mass,  but  that  a  further  examination  after  the  bowel  had  been 
emptied  was  advisable  to  ascertain  the  cause  of  the  accumulation. 
To  this,  however,  he  would  not  agree,  as  he  considered  himself 
cured.  A  year  later  this  patient  had  an  attack  of  acute  obstruction, 
and  colotomy  was  performed.  It  was  then  discovered  that  there 
was  a  cancer  of  the  sigmoid  flexure,  which  had  doubtless  been 
present  before,  and  could  have  been  detected  had  he  submitted  to 
be  examined  properly. 


233 


Chapter    XVI. 

SIMPLE    STRICTURE    OF    THE    COLON 
AND    EMBOLISM    OF    THE    MESOCOLIC    VESSELS. 

SIMPLE     STRICTURE. 

Compared  with  malignant  stricture  this  is  a  rare  condition. 
Cases  of  simple  (non-malignant)  stricture  may  be  divided  into 
three  kinds  : — 

1.  Stricture  due  to  hyperplastic  tuberculosis. 

2.  Stricture  due  to  pericolitis. 

3.  Cicatricial  strictures  the  result  of  ulceration. 

The  first  two  conditions  are  commonly  mistaken  for  cancer, 
and  so  close  is  the  resemblance  that  it  is  often  only  possible  to 
be  certain  of  their  benign  nature  after  careful  microscopical 
•examination.  Both  in  hyperplastic  tuberculosis  and  pericolitis 
the  stricture  is  accompanied  by  considerable  tumour  formation. 
These  conditions  will,  however,  not  be  further  considered 
here,  as  they  have  already  been  described  in  Chapters  XIII. 
and  XIV. 

Cicatricial  stricture  of  the  colon  is  a  very  rare  condition. 
Out  of  669  cases  of  intestinal  obstruction  collected  by  the 
late  H.  L.  Barnard  from  the  records  of  the  London  Hospital, 
there  were  only  four  of  simple  stricture  of  the  colon,  and  these 
were  all  in  the  sigmoid  flexure. 

Simple  stricture  of  the  colon,  as  also  of  the  rectum,  has  been 
supposed  to  be  a  result  of  tertiary  syphilis  ;  but  after  careful 
search,  I  have  not  succeeded  in  finding  a  single  instance  of 
■an  undoubted  syphilitic  lesion,  much  less  of  a  syphilitic 
stricture. 

It  may  be  congenital,  and  in  Chapter  VI.  several  such  cases 
are  given.  The  commonest  cause  is  undoubtedly  the  contraction 
following  severe  chronic  ulceration.  As  I  have  already  pointed 
out,  most  ulcers  of  the  colon  heal,  if  at  all,  without  leaving  much 
scarring.     If  the  ulcer  is  very  large,  however,  and  has  entirely 


234  SIMPLE     STRICTURE 

destroyed  the  mucous  membrane,  scarring  and  contraction  may 
result.     This  is  especially  the  case  v/ith  chronic  ulcers.* 

I  have  seen  one  case  of  a  diaphragm- Hke  stricture  of  the  pelvic 
colon  in  which  the  condition  appeared  to  have  resulted  from 
previous  ulceration.  In  St.  Bartholomew's  Hospital  museum 
there  is  a  very  interesting  specimen  (see  Fig.  58)  of  a  cicatricial 
stricture  in  the  middle  of  the  transverse  colon.  There  are  a 
number  of  curious  thread-like  polypi  hanging  from  the  mucous 
membrane  in  the  neighbourhood  of  the  stricture.  Curiously 
enough,  dysenteric  ulceration  apparently  never  results  in 
stricture.  Thus,  out  of  the  records  of  287,522  cases  of 
dysentery  occurring  among  the  troops  in  the  American  Civil 
War,  there  was  no  single  instance  of  a  stricture  of  the  colon. 

A  very  moderate  degree  of  stricture  in  the  descending  or  pelvic 
portions  of  the  colon  will  cause  obstruction,  owing  to  the  solid 
nature  of  the  contents.  When  acute  obstruction  occurs  from  a 
simple  stricture,  the  actual  cause  of  the  blockage  is  always  faecal 
impaction. 

Most  of  these  cicatricial  strictures  are  complicated  by  the 
presence  of  adhesions  around  the  bowel  which,  like  the  stricture, 
have  resulted  from  the  previous  ulceration. 

The  changes  which  occur  in  the  bowel  above  the  stricture  are 
those  usually  associated  with  a  chronic  partial  obstruction.  The 
bowel  is  dilated  and  its  walls  are  markedly  hypertrophied. 
Stercoral  ulceration  may  be  present,  and  in  some  cases  multiple 
polypi  have  been  found  growing  from  the  mucous  membrane 
just  above  the  stricture.  The  formation  of  stercoliths  thus 
situated  has  already  been  referred  to  in  Chapter  XV. 

Treatment. 
The  condition  may  be  treated  either  by  resection  of  the  affected 


*  The  following  case  is  recorded  by  Quenu  and  Duval  {Rev.  de  Chivurgie, 
Dec.  10,  1902).  The  patient  was  a  man,  age  67.  For  some  time  he 
had  complained  of  pain  in  the  abdomen,  and  sufiered  from  habitual 
constipation.  His  bowels  were  for  long  periods  unrelieved.  Examination 
of  the  abdomen  revealed  a  hard  cylindrical  mass  in  the  csecal  region. 
Nothing  could  be  felt  per  rectum,  and  intestinal  obstruction  probably 
due  to  cancer  was  diagnosed.  The  patient  refused  to  be  operated 
upon,  and  died.  Post  mortem,  a  large  abscess  cavity,  shut  off  by 
adhesions,  was  discovered  in  the  lower  part  of  the  abdomen.  This 
cavity  communicated  with  the  sigmoid  flexure  by  a  perforation  at  the 
bottom  of  an  old  ulcer.  The  contraction  of  the  ulcer  had  caused  an. 
annular  constriction  which  almost  occluded  the  bowel. 


OF    THE     COLON  235 

portion  of  bowel,  or  by  incising  the  bowel-wall  over  and  through 
the  stricture,  and  then  sewing  up  the  resulting  wound  in  a 
transverse  direction.  The  operation  is,  however,  often  much 
complicated  by  the  presence  of  adhesions  in  the  neighbourhood, 
and  it  may  sometimes  be  better  to  deal  with  the  case  by  short- 
circuiting  the  affected  portion  of  bowel  by  lateral  anastamosis. 

THROMBOSIS     OR     EMBOLISM     OF     THE     COLIC 
BLOOD-VESSELS. 

Embolism  of  one  of  the  main  arteries  of  the  colon,  or  thrombosis 
of  the  veins,  results  in  complete  obstruction.  The  contents  of 
the  colon  are  arrested  and  the  bowel  above  becomes  distended. 
Thrombosis  is  a  very  rare  condition,  and  is  but  seldom  diagnosed 
during  life. 

The  symptoms  produced  by  embolism  or  thrombosis  are  those 
of  intestinal  obstruction,  and  it  is  not  possible  to  make  a  correct 
diagnosis  unless  there  is  some  reason  to  expect  embolism. 
Exactly  why  an  infarcted  portion  of  the  colon  should  produce 
obstruction  it  is  not  easy  to  see  ;  but  it  apparently  acts  as  a 
complete  block  to  the  passage  of  the  intestinal  contents,  and  the 
bowel  above  becomes  dilated  as  if  a  stricture  were  present. 
When  seen,  the  appearance  of  the  bowel  is  characteristic.  It 
is  of  a  dark  chocolate  colour,  and  in  marked  contrast  to  the 
surrounding  healthy  bowel.  When  laid  open,  the  mucous 
membrane  is  seen  to  be  purplish  in  colour  and  oedematous. 

For  the  notes  of  the  following  case,  which  well  illustrate  this 
rare  and  interesting  condition,  I  am  indebted  to  Mr.  Littlewood, 
of  Leeds. 

The  patient  was  a  woman,  aged  64.  She  was  much  wasted. 
There  was  a  history  of  several  days'  complete  intestinal  obstruc- 
tion, with  faecal  vomiting  and  some  abdominal  distention.  There 
was  no  history  of  mel£ena,  and  no  evidence  on  examination  of 
any  cardiac  lesion. 

An  exploratory  laparotomy  was  performed.  The  patient  was 
very  ill,  and  died  on  the  operating-table.  A  post-mortem  examina- 
tion revealed  in  the  left  half  of  the  transverse  colon  a  portion 
about  2|  to  3  inches  in  length  which  was  thickened  and  oedema- 
tous. The  corresponding  portion  of  mesocolon  was  similarly 
thickened,  and  both  this  and  the  bowel-wall  were  markedly 
injected.  On  opening  the  gut,  the  mucous  membrane  was  seen 
to  be  of  a  chocolate  colour,  and  slightly  swollen.     The  affected 


236    EMBOLISM  OF  COLIC  BLOOD-VESSELS 

portion  of  mucous  membrane  was,  owing  to  the  change  in 
colour,  sharply  marked  off  from  the  normal  mucosa.  There 
was  well-marked  venous  dilatation. 

Thrombosis  was  discovered.  One  small  artery  near  the  bowel 
contained  blood-clot,  but  the  clot  was  not  apparently  attached 
to  the  vessel  wall.  The  colon  was  distended,  and  the  discoloured 
portion  of  the  transverse  colon  marked  the  junction  between  the 
distended  and  collapsed  portions  of  bowel.  The  caecum  was 
greatly  distended,  and  there  was  distention  of  the  ascending  and 
right  half  of  the  transverse  colon  ;  but  the  distention  termi- 
nated at  the  discoloured  portion  of  bowel,  and  the  descending 
colon  was  collapsed. 

The  remainder  of  the  intestine  was  quite  normal,  as  were  also 
the  other  abdominal  organs. 

Treatment. 

When  an  extensive  area  of  colon  is  involved,  it  is  unlikely 
that  any  operative  or  other  treatment  will  avail.  But  if  the 
infarcted  area  is  not  large,  and  operation  is  performed  early, 
resection  of  the  whole  damaged  area  of  bowel  will  probably  save 
the  patient's  life. 

It  is  unhkely  that  the  condition  will  be  diagnosed  previous  to 
operation  ;  but  as  the  symptoms  are  those  of  intestinal  obstruc- 
tion, a  condition  calhng  for  immediate  operative  interference, 
this  is  not  a  serious  obstacle  to  a  successful  result. 


237 


Chapter    XVII. 

SIMPLE    TUMOURS    OF    THE    COLON. 

Simple  tumours  are  not  very  common  in  the  colon.  Fibrous 
tumours,  the  result  of  diverticula  and  pericolitis,  and  hyper- 
plastic tuberculosis,  are  sometimes  found,  and  have  already 
been  referred  to  under  these  headings.  These  fibrous  tumours, 
however,  are  inflammatory  in  origin,  and  not  true  tumours. 
Lipomata  are  occasionally  found  in  connection  with  the  colon  ; 
but  they  are  rare,  and  seldom  cause  symptoms  unless  of  very 
large  size.  Mr.  Bland-Sutton,  in  his  book  on  tumours,  relates 
a  case  in  which  he  removed  a  lipoma  of  the  ascending  colon 
which  was  causing  obstruction. 

Villous  adenomata  occur  in  the  colon  ;  but  they  are  seldom 
detected  before  they  have  become  mahgnant.  In  most  cases, 
when  removed,  they  are  found  to  show  well-marked  malignant 
changes,  and  are  therefore  usually  classified  as  malignant 
tumours.  Single  polypi  are  occasionally  met  with,  and  are  a 
well-known  cause  of  intussusception ;  their  structure  is  usually 
adenomatous,  and  they  have  a  long  pedicle  produced  by  the 
action  of  peristalsis  in  attempting  to  move  them  along  the 
bowel  lumen. 

Multiple  Polypi  of  the  Colon. — One  of  the  most  interesting 
and  curious  forms  of  simple  tumour  of  the  colon  is  the  condition 
described  as  multiple  polypi.  It  is  also  described  as  multiple 
adenomata  and  colitis  polyposa. 

The  condition  is  rare  ;  but  I  have  been  able  to  collect  a 
number  of  cases  ;  and  several  drawings  and  photographs  of  the 
condition  are  appended. 

"  Multiple  polypi  of  the  colon  "  is  not  a  pathological  entity, 
but  includes  several  distinct  diseases  which  have  been  described 
under  this  name. 

Multiple  polypi  may  be  divided  into  four  classes,  as 
follows  : — (i)  True  multiple  adenomata ;  (2)  Polypi  found  in 
association  with   hyperplastic  tuberculosis  ;   (3)  Multiple  polypi 


238  SIMPLE    TUMOURS 

found  in  association  with  an  old  stricture  of  the  colon  ;  (4)  The 
polypoid  condition  of  the  mucosa  which  sometimes  results  from 
ulcerative  colitis. 


^'S-  53- — Multiple  adenorr.ata.    (.)/;-.  Frcd'c.  WalUs's  case.     Charing  Cross  Hospital  Museum.) 

I.  True  Multiple  Adenomata. — This  is  a  curious  condition 
in  which  there  are  numbers  of  small  adenomata  growing  from 
the  mucous  membrane  of  the  colon.  It  was  first  described  by 
Virchow  in  a  paper  written  in  1863. 


OF    THE    COLON 


239 


The  number  and  size  of  the  polypi  vary  considerably  in 
different  cases.  They  may  be  quite  small  and  very  numerous, 
so  numerous  in  fact  that  the  entire  colon  is  covered  with  them, 
or  they  may  be  large  and  comparatively  limited  in  number. 

There  appear  to  be  two  distinct  types  :  one  in  which  the  entire 
colon  is  covered  with  small  semi-pedunculated  polyps  in  such 


\  •>       fi^-i 


7v>.  54. — Multiple  polypi  of  the  colon  (Charing  Cross  Hospital  Museum}. 


numbers  that  the  mucosa  is  almost  hidden.  The  two  best- 
marked  cases  of  this  tj^e  are  : — Mr.  F.  Wallis's  case,  the 
specimen  of  which  is  in  Charing  Cross  Hospital  (see  Fig.  53),  and 
Lienthall's  case.  In  the  former  there  was  a  similar  condition  in 
che  stomach,  and  in  part  of  the  small  intestine,  and  the  condition 


240 


SIMPLE    TUMOURS 


resembled  lymphadenoma.     In  Lienthall's  case  the  disease  was 
apparently  confined  to  the  colon.     This  type  is  extremely  rare. 

In  the  other  and  commoner  class  there  are  numerous  polypi  of 
all  sizes  and  shapes,  some  of  them  sessile,  but  the  majority 
pedunculated.  The  sessile  polypi  appear  to  be  but  the  early 
condition  of  the  large  pedunculated  ones.  They  are  often  large, 
and  may  have   pedicles   an   inch   or  more  in  length.      In  one 


^^H^^ 

i 

■•,-■  ■j/v^''^       ^                               ^ 

B^r-r. 

^ 

■^'£-  55.— Multiple  polypi  of  the  color,  associated  with  a  cancerous  stricture. 
(From  a  specimen  in  the  Great  Northern  Hospital  Museum.) 


of  my  cases  a  polypus  which  broke  off  and  was  passed  per 
anum  was  as  large  as  a  walnut,  and  had  a  long  narrow,  ribbon- 
like stem. 

There   may   be   great   numbers   of   these   polypi   distributed 


OF    THE    COLON  241 

throughout  the  colon.  There  are  usually  numerous  quite  small 
and  undeveloped  potypi  to  be  seen,  and  if  these  are  examined 
the}^  are  found  to  be  growing  from  the  free  edges  of  the  valvulse 
conniventes.  An  examination  of  several  specimens  makes  it 
seem  probable  that  the  polypi  all  originate  as  outgrowths  from 
the  edges  of  these  folds.     (See  Fig.  57.) 

They  are,  as  a  rule,  most  numerous  in  the  pelvic  and  descending 
portions  of  the  colon.  The  rectum  is  also  commonly  affected. 
The  pol^'pi  in  the  rectum  are  naturally  the  most  easily  detected, 
and  in  several  instances  the  condition  is  described  as  multiple 
polypi  of  the  rectum.  But  I  have  found  no  case  in  which  the 
condition  was  confined  to  the  rectum  ;  careful  investigation  or 
post-mortem  examination  always  proves  the  colon  also  to  be 
affected,  while  in  some  the  rectum  is  not  affected  at  all. 

The  condition  is  always  accompanied  by  a  certain  amount  of 
inflammation  of  the  mucous  membrane,  and  gives  rise  to  severe 
and  intractable  diarrhoea  and  haemorrhage. 

The  Microscopical  Appearances.  —  When  sections  are 
examined  under  the  microscope  these  poK^i  can  be  seen  to 
consist  of  a  central  mass  of  typical  adenoid  tissue,  covered 
outside  with  the  ordinary  columnar-celled  epithelium  of  the 
colon.  They  are  not,  however,  simple  outgrowths  or  excres- 
cences of  the  mucous  membrane,  as  the  submucous  coat  is 
represented.  A  careful  microscopical  examination  shows  that 
they  originate  beneath  the  mucous  membrane,  probably  in  the 
solitary  follicles,  and,  as  they  protrude  into  the  bowel,  become 
covered  and  surrounded  by  the  mucous  membrane.  In  the 
pedunculated  variety  there  is,  as  a  rule,  no  adenoid  tissue  in  the 
pedicle,  which  consists  of  a  tube  of  mucous  membrane  enclosing 
connective  tissue  continuous  with  the  submucous  layer  of  the 
bowel-wall. 

Little  is  known  as  to  the  etiology  of  these  polypi.  The  condi- 
tion occurs  at  all  ages  and  about  equally  in  the  two  sexes.  The 
most  probable  explanation  is  that  they  arise  from  irritation.  I 
recently  saw  a  case  in  which  the  condition  occurred  in  a  child  of 
four  as  the  result  of  worms.  The  fact,  already  mentioned,  that 
there  are  almost  invariably  chronic  inflammatorv  changes  in  the 
mucous  membrane,  supports  the  same  view,  v/hich  is  further 
strengthened  by  pohrpi  being  often  found  associated  with 
simple  stricture  of  the  colon  and  v/ith  hyperplastic  tuberculosis. 

Secondary   Changes   in   the   Polypi. — The   larger  poljrpi, 

16 


242 


SIMPLE    TUMOURS 


especially  those  near  the  lower  end  of  the  pelvic  colon,  tend  to 
become  ulcerated  from  the  traumatism  to  which  they  are  sub- 
jected by  the  passage  of  the  faeces. 

What  is  of  much  greater  importance,  however,  is,  that  there 
is  a  marked  tendenc v  for  some  of  the  polypi  to  become  malignant 
and  cause  an  adeno-carcinomatous  stricture.  This  is  particularly 
liable  to  occur  at  those  parts  of  the  colon,  such  as  the  sigmoid 


/''/f.  56. — Multiple  polypi  of  the  colon  with  secondary  cancer  {Dlr.  Gordon  ll'a/so/i's  case). 


flexure,  where  the  polypi  are  most  numerous  and  most  subjected 
to  traumatism  from  hard  faecal  material. 

In  two  of  my  cases  there  was  already  a  cancerous  stricture  in 
the  sigmoid  flexure  ;  and  in  another  there  was  evidence  of  cancer 
some  months  after  the  case  was  first  seen.  In  this  latter  case 
numerous  polvpi  could  be  seen  with  the  sigmoidoscope  in  the 


OF    THE    COLON  243 

sigmoid  flexure  and  the  rectum.  All  the  polypi  in  the  rectum 
that  could  be  reached  were  removed.  One  of  these  was  examined, 
and  showed  the  typical  structure  of  simple  adenoma.  Some 
months  later  the  patient  developed  symptoms  of  cancer  in  the 
sigmoid,  but  was  too  ill  to  return  to  the  hospital. 

In  one  of  the  cases  there  was  a  carcinomatous  stricture  in  the 
sigmoid,  which  was  resected.  On  examination  of  the  specimen 
it  was  evident  that  the  growth  had  arisen  in  one  of  the  polypi. 
Two  of  the  pol3-pi  at  some  distance  from  the  growth  were 
examined,  and  while  one  was  a  simple  adenoma,  the  other 
showed  signs  of  commencing  malignancy.     (See  Fig.  56.) 

Out  of  the  forty-two  cases  of  multiple  polypi  of  the  rectum  or 
colon  collected  by  Ouenu  and  Landel,  in  twenty  cancer  was 
either  present  when  the  case  was  examined,  or  developed  later. 

In  one  of  my  cases  the  patient  was  operated  upon  for  cancer 
.of  the  sigmoid,  and  the  bowel  was  resected.  No  polypi  were 
seen  in  the  resected  portion  ;  but  a  year  later  he  returned  with 
.recurrence  of  symptoms,  and  on  examination  with  the  sigmoido- 
scope several  pedunculated  polypi  were  seen,  some  six  inches 
above  the  old  line  of  anastomosis.  The  patient  died  from  a 
second  operation,  and,  post  mortem,  there  were  some  half-dozen 
.polypi,  the  highest  of  which  was  eight  inches  above  the  line  of 
the  original  anastomosis.  There  was  no  recurrence  at  the 
original  site  ;  but  on  examining  several  of  the  polypi,  tw^o  were 
found  to  be  malignant. 

Symptoms. 

The  most  marked  symptom  is  diarrhoea.  This  is  severe  and 
intractable.  The  patient  rapidly  wastes  and  becomes  emaciated 
as  the  result  of  the  constant  loss  of  fluid,  and  there  is  not 
infrequently  considerable  tenesmus.  The  stools  are  Liquid  and 
contain  much  slimy  mucus.  Blood  is  frequently  present  in  the 
stools  and  is  intimately  mixed  with  them.  The  symptoms 
closely  resemble  those  of  cancer  or  ulceration  of  the  colon  ; 
but  the  diarrhoea  is,  as  a  rule,  more  severe.  Abdominal  pain 
is  usually  present,  and  in  most  of  the  cases  there  has  been 
severe  pain  in  the  left  side  of  the  abdomen.  There  is,  as 
stated  before,  often  marked  anaemia. 

There  is  usually  a  history  of  bleeding  and  diarrhoea  for  long 
periods.  Thus,  in  one  patient  there  had  been  almost  continuous 
bleeding  for  ten    years  ;    and    in   another   the   symptoms    had 


244  SIMPLE    TUMOURS 

persisted  without  intermission  for  three.  In  one  very  remarl^c- 
able  instance  three  members  of  a  family  suffered  from  the 
condition  ;  but  I  have  been  unable  to  find  another  similar  case. 

An  examination  of  the  rectum  usually  reveals  the  presence  of 
a  number  of  polypi  scattered  over  the  mucous  membrane,  and 
the  sigmoidoscope  shows  a  similar  condition  in  the  pelvic  colon. 
The  colon  is  tender  when  palpated  through  the  abdominal  wall. 
The  following  are  typical  cases  of  the  condition  : — 
Author's  Case. — A  woman,  aged  57.  The  patient  was  quite 
well  until  August,  1907,  when  she  began  to  suffer  from  diarrhoea. 
This  continued  intermittently  until  October,  when  she  began  to 
notice  blood  in  the  stools,  and  had  severe  pain  in  the  left  side  of 
the  abdomen.  These  symptoms  continued  until  her  admission 
to  hospital  in  January,  1908.  At  this  time  there  were  con- 
stant diarrhoea  and  much  blood  and  mucus  in  the  stools.  On 
examination,  there  were  numerous  polypi  in  the  rectum. 
The  sigmoidoscope  showed  numerous  polypi  growing  from  the 
mucous  membrane  of  the  pelvic  colon  as  far  up  as  could  be  seen. 
They  varied  in  size  from  quite  small  sessile  polyps  to  peduncu- 
lated growths  nearly  as  large  as  a  walnut.  At  one  spot  there 
was  some  ulceration  of  one  of  the  polyps,  which  suggested  possible 
commencing  malignant  disease.  Under  an  anaesthetic  some  of 
the  polypi  in  the  rectum  were  removed,  and  on  examination 
showed  a  simple  adenomatous  structure.  The  patient  left  the 
hospital  and  returned  home.  When  heard  from  in  November 
she  was  still  very  ill,  and  there  appeared  to  be  symptoms  of 
malignant  stricture.  In  December, her  doctor  sent  me  a  large 
polypus  which  had  passed  per  anum  ;  on  having  sections  of 
it  cut,  the  typical  structure  of  an  adeno-carcinoma  could  be  seen, 
so  that  there  was  no  doubt  malignant  change  had  occurred. 

Case  cf  Multiple  Polypi' of  the  Colon  Associated  with  Cancerous 
Stricture  cf  the  Sigmoid  Flexure. — Specimen  in  St.  Bartholomew's 
Hospital  Museum  (No.  2065).  The  patient  was  a  man,  aged  20, 
who  died  in  the  hospital.  Ten  years  previously  he  was  taken 
into  the  London  Hospital  for  haemorrhage  from  the  bowel,  and 
was  operated  upon  there.  The  bleeding  returned  in  a  few 
months  ;  and,  at  intervals,  he  had  haemorrhage  for  the  next 
four  years.  Several  further  operations  were  performed,  and 
polypi  removed ;  but  with  only  temporary  rehef  from  the 
bleeding.  A  brother  and  sister  of  this  patient  were  also  under 
treatment  at  St.  Bartholomew's,  and  were  found  on  examination 


OF    THE    COLON 


245 


also  to  have  multiple  polypi  of  the  bowel.  On  admission  the 
patient  was  very  anaemic,  and  complained  of  pain  in  the  rectum. 
There  was  an  almost  constant  discharge  of  blood  and  mucus 
from  the  bowel.  On  dilating  his  rectum  under  an  anaesthetic 
numerous  polypi  could  be  seen  in  the  rectum,  and  several  of 
these  were  removed.     He    was    re-admitted   into   the   hospital 


n 

'^ 

""^^M 

<iji«^«>.    '■'^ 

"''^S 

^■ 

'  ^Mmi^^^^^BBiB 

^™i^R 

V 

''^^^ral^^^^^^^l 

^^^' 

Hfe*(-3^<'*  J 

m^a^ 

^9^H^H[ 

1 

te 

^^^■^^^^^^1 

■»  "i?»-i?-- 

v'''4^  57. — Multiple  polypi  of  the  colon.     (Author's  cast'.) 


three  limes,  on  the  last  occasion  with  symptoms  of  peritonitis, 
from  which  he  died. 

An  examination  of  the  specimen  shows  an  adeno-carcinoma- 
tous  growth  at  the  recto-sigmoidal  junction  surrounding  the 
bowel  and  almost  obliterating  it.  Below  the  stricture  there  are 
numerous  polypoid  growths  scattered  over  the  bowel  walls. 
There  are  also  several  above  the  stricture,  and  in  the  ascending 


246  SIMPLE    TUMOURS 

and  transverse  portions  of  the  colon  are  three  or  four  polypi. 
The  colon  above  the  stricture  is  enormously  dilated,  and  the 
peritoneum  over  the  anterior  band  has  split  from  the  distention. 
Most  of  the  polypi  are  globular,  with  narrow  pedicles,  but  "some 
are  sessile  or  ribbon-like  structures.  The  microscopical  examina- 
tion shows  the  growth  to  be  an  adeno-carcinoma.  The  polypi  are 
simple  adenomata. 

A  case*  is  reported  by  A.  Samuels  of  a  woman,  aged  48,  who 
for  three-and-a-half  years  had  suffered  from  frequent  watery 
stools  containing  blood,  and  occasional  vomiting.  There  was 
constant  pain  in  the  left  side  and  considerable  loss  of  weight. 
The  abdomen  was  opened  and  the  colon  incised.  Numerous 
polypi  were  found  in  the  colon,  and  a  large  number  were  removed. 
The  patient  was  better  after  operation  ;  but  there  were  occasional 
recurrences  during  the  next  two  years.  Microscopically  the 
polypi  removed  proved  to  be  simple  adenomata. 

2.  Polypi  in  Association  with  Hyperplastic  Tuberculosis. 
■ — These  have  already  been  described  in  dealing  with  tubercle 
of  the  colon.  They  occur  in  or  just  above  the  stricture. 
They  may  contain  giant  cells  and  tubercle  bacilh.  They  may 
be  present  in  considerable  numbers  and  have  long  pedicles. 

3.  Polypi  in  Association  with  an  old  Stricture. — These 
polypi  are  verj/  curious.  They  are  filiform  structures,  often 
of  most  curious  and  eccentric  shapes,  and  several  inches  long. 
They  are  often  looped  or  fork-shaped.  They  are  in  appear- 
ance quite  unlike  the  polypi  previously  described ;  and  are 
only  found  in  and  just  above  and  below  an  old  simple  stricture. 
(See  Fig.  58.)  They  consist  of  connective  tissue  covered  b3^ 
mucous  membrane.  - 

4.  Polypoid  Condition  Associated  with  Ulcerative  Colitis- 
— These  are  not  true  polypi,  though  their  appearance  is 
very  similar,  but  are  the  islands  of  mucous  membrane  left 
between  the  ulcerated  areas.  Each  of  these  becomes  partty 
undermined  by  the  ulceration,  and  thus  a  pedicle  is  formed. 
The  mucous  membrane  becomes  swollen  and  hypertrophied, 
and  in  this  way  the  appearance  of  a  poH^us  is  produced. 

Treatment  of  Cases  of  Multiple  Polypi  of  the  Colon. 
Those  forms  of  polypi  accompanying  tuberculosis  and  stricture 

*  Surg.   GyncBCol.   and  Obstet.  1509,  p.  380. 


OF    THE     COLON 


247 


of  the  colon  do  not  call  for  any  treatment  apart  from  the  condi- 
tion with  which  they  are  associated. 

The  treatment  of  multiple  adenomata  is  a  very  difficult 
matter.  In  most  cases  the  condition  has  only  been  detected  in 
the  rectum,  and  it  has  been  supposed  that  the  pol^'pi  were 
confined  to  this  part  of  the  bowel,  whereas  they  really  extended 
more  or  less  throu,?hout  the  large  bowel.     Most  of  the  operations 


Fig.  58. — Drawing  of  a  specimen  in  St.  Dartholomew's  Hospital  Museum,  showing  a  simple 
fibrous  stricture  in  the  centre  of  the  transverse  colon,  and  numerous  filiform  polypi  growing 
from  the  mucous  membrane  above  the  stricture.     The  colon  above  the  strictuie  is  dilated. 


performed  have  been  confined  to  the  removal  of  as  many  polypi 
as  possible  from  the  rectum,  and  in  some  cases  forty  or  fifty  have 
thus  been  removed.  Such  operations  have,  however,  done  no 
good,  and  the  symptoms  have  persisted  as  before.  In  a  few  the 
anus  and  rectum  have  been  laid  open,  to  enable  more  polypi  to 
be  reached.     Left   inguinal   colotomy  has  also  been  done  with 


248     SIMPLE  TUMOURS   OF  THE   COLON 

the  object  of  deflecting  the  fsecal  current  ;  but  has  been  equally 
useless,  because  the  opening  was  not  above  the  disease. 

Cascostomy  has  also  been  performed.  This  was  done  in 
Lienthall's  case,  and  the  patient's  symptoms  were  somewhat 
alleviated  ;  but  no  diminution  in  the  size  or  number  of  the 
polypi  resulted. 

None  of  these  operations  seem  of  the  least  use,  and  they 
should  certainly  not  be  performed.  Colotomy  does  not  relieve 
the  sjnnptoms,  and  merely  adds  to  the  patient's  distress. 

The  disease  is  a  very  serious  one.  The  patient  suffers  from 
severe  and  intractable  diarrhoea  and  bleeding.  There  is  often 
severe  and  distressing  tenesmus,  and  rapid  loss  of  weight  and 
wasting.  Moreover,  there  is  every  probability  that  cancer  will 
develop,  if  it  has  not  already  done  so. 

Under  these  circumstances  any  operation  would  seem  justifi- 
able that  affords  a  possibility  of  removing  the  disease.  The 
only  method  that  offers  any  reasonable  prospect  of  deahng 
adequately  with  it  is  resection  of  the  entire  colon.  This  was 
done  in  Lienthall's  case  after  a  previous  ileo-sigmoidostomy,  and 
the  patient  recovered.  This  was  probably  the  first  instance  in 
which  resection  of  the  entire  colon  was  performed. 

Unfortunately,  the  rectum  is  usually  affected  together  with 
the  colon,  so  that  the  whole  of  the  disease  cannot  be  removed  ; 
but  if  the  anastomosis  is  made  low  down,  the  polypi  in  the  rectum 
could  in  most  cases  be  removed  later  ;  and,  at  any  rate,  this 
operation  seems  to  be  the  only  one  at  all  worth  considering. 

Resection  of  a  cancer  of  the  colon  which  is  found  to  be  associ- 
ated with  multiple  polypi  is  apparently  not  worth  doing  unless 
the  rest  of  the  colon  is  either  removed  at  the  same  time  or 
subsequently.  The  evidence  available  seems  to  show  that  cancer 
will  recur  in  some  other  part  of  the  colon  if  it  has  not  already 
done  so. 


249 


Chapter  XVIII. 

MALIGNANT    DISEASE    OF    THE    COLON. 

The  commonest  form  of  malignant  disease  met  with  in  the  colon 
is  adeno-carcinoma.  Cancer  of  the  colon  is  a  comparatively 
common  disease ;  indeed,  of  all  the  different  diseases  to  which 
the  colon  is  liable,  cancer  is  probably  one  of  the  commonest. 
Neither  is  it  confined  to  the  later  periods  of  life,  for  it  appears 
often  to  affect  the  colon  at  an  earlier  age  than  with  many  other 
parts  of  the  body.  Out  of  loo  cases  collected  from  various 
sources,  I  found  that  eleven  were  under  30  years  of  age,  and 
four  under  20.  The  youngest  patient  was  a  child,  age  5,  and 
another  was  only  12  years  old.  Mr.  Mayo  Robson  also  records 
the  case  of  a  child  aged  14  with  cancer  of  the  colon. 

The  two  sexes  seem  to  be  about  equally  affected.  In  my 
series  55  patients  were  males  and  45  females. 

Situation  of  the  Growth. — The  following  four  series  of 
cases  show  the  comparative  frequency  of  cancer  in  different 
portions  of  the  colon  : — 


Situation 

London      i      Clogg's 
Hospital.          Series. 

Tuttle's 
Series. 

Lichtenstf.in's 
Serces. 

Caecum     .  . 
Ascending   Colon 
Hepatic   Flexure 
Transverse  Colon 
Splenic  Flexure  . 
Descending  Colon 
Sigmoid    Flexure 

41 
6 

3 

17 
12 

6 
103 

17 

5 

3 
10 

o7 

I 

r    283 
'-    160 

32 

6 

1  ■= 

1 1 

42 

Total 

188 

72 

625 

121 

It  will  thus  be  seen  that  the  sigmoid  flexure  is  the  commonest 
situation  ;  next  the  caecum  and  ascending  colon  ;  then  the 
transverse  colon  or  splenic  flexure.  The  parts  least  commonly 
affected  are  the  hepatic  flexure  and  the  descending  colon.     The 


250  MALIGNANT    DISEASE 

dependent  parts  of  the  colon  are  those  most  commonly  affected 
with  cancer,  namely  the  caecum,  middle  of  the  transverse  colon, 
and  the  sigmoid  flexure.  It  is  in  these  regions  of  the  bowel  that 
stagnation  of  the  contents  tends  to  occur  most  frequently. 

Predisposing  Causes  of  Cancer  of  the  Colon. — Of  the 
real  causes  of  cancer  of  the  colon,  or  elsewhere,  we  at  present 
know  nothing,  and  the  predisposing  causes  are  chiefly  of  import- 
ance in  that  they  may  help  us  in  forming  an  opinion  as  to  the 
prognosis  in  cases  in  which  we  know  that  such  causes  exist,  and 
in  determining,  whether  or  no  an  operation  should  be  under- 
taken to  remove  some  lesion  which  may  later  become  a  site  of 
cancer.  Prof.  Nothnagel  has  stated  that  cancer  of  the  bowel 
not  infrequently  arises  at  the  site  of  an  ulcer  of  simple  origin 
in  the  mucous  membrane. 

That  a  congenital  abnormality  of  the  colon  may  be  a  predispos- 
ing cause  seems  probable.  A  case  is  recorded  by  Lockwood,  in 
which  the  descending  colon  was  double,  and  at  the  site  of 
junction  of  the  two  tubes  there  was  a  cancerous  tumour. 

Polypi  appear  to  be  a  common  predisposing  cause  of  cancer. 
The  history  in  vaany  cases  clearly  shows  their  presence  for  a 
considerable  time  before  the  cancer  started.  These  cases  are 
dealt  with  in  full  in  considering  the  subject  of  multiple  polypi. 

Morbid  Anatomy. — Cancer  of  the  colon  always  originates  in 
the  glands  of  Lieberkiihn,  and  is  of  the  so-called  columnar-celled 
variety,  or  aden-ocarcinoma.  No  other  type  of  carcinoma  occurs 
in  the  colon,  though  there  may  be  considerable  variations  due  to 
secondary  or  degenerative  changes.  Colloid  degeneration  is 
not  uncommon,  and  in  rapidh^  growing  tumours  the  so-called 
encephaloid  type  of  degeneration  is  seen.  Occasionally  there  is 
a  tendency  for  the  fibrous-tissue  elements  to  preponderate,  and 
this  results  in  the  scirrhous  type  of  growth.  Scirrhous  carcinoma 
is  most  common  in  growths  of  the  sigmoid  ;  but  it  is  always  a 
rare  form  of  cancer  of  the  colon.  The  scirrhous  growths  do  not 
project  into  the  bowel,  but  cause  a  tight  stricture  of  the  lumen 
due  to  the  growth  spreading  circularly  in  the  submucous  layer. 
The  appearance  of  such  tumours  is  often  that  of  a  tight  ring-like 
stricture,  the  outside  of  the  bowel  being  grooved  as  if  a  string 
had  been  tied  round  it.  These  scirrhous  growths  may  cause 
considerable  stricture  without  any  ulceration  of  the  mucosa. 

The  common  adeno-carcinoma  is  a  more  or  less  nodular  or 
cauhflower-like  outgrowth   of  the   mucosa  projecting  into  the 


PLATE    V 


Cancer  of  the  Pelvic  Colon  as  seen  through  the  sigmoidoscope. 


OF    THE    COLON  251 

bowel  lumen.  The  surface  may  or  mav  not  be  ulcerated,  depend- 
ing upon  the  time  it  has  existed  and  the  amount  of  traumatism 
to  which  it  has  been  subjected.  On  the  outside  of  the  bowel, 
over  the  base  of  such  a  tumour,  there  is  generally  a  scar-like 
depression  or  hollow,  and  in  addition  to  the  narrowing  of  the 
lumen  caused  bv  the  tumour,  there  is  almost  invariably  a  certain 
amount  of  contraction.  Rarely,  the  tumour  exists  as  a  polypus 
hanging  loose  in  the  bowel  lumen,  and  in  one  of  my  cases  there 
were  several  such  polvpi  showing  malignant  changes.  (See 
Fig.  64.) 


y-'/V  59. — An  early  carcinomatous  ulcer  of  tlie  sigmoid  flexure.     Resecced  by  the  author 
from  a  man,  age  46. 

All  cancers  found  in  the  colon  are,  however,  essentially  the 
same,  namely,  adeno-carcinomata,  and  the  various  different 
tvpes  often  described  are  merelv  due  to  degenerative  or  other 
changes. 

Cancer  of  the  colon  is  almost  invariablv  a  primary  lesion  ; 
but  there  are  a  few  rare  and  interesting  cases  where  the  growth 
appears  to  be  secondary  to  another,  higher  up  in  the  alimen- 
tary canal.  In  these  rare  instances  of  secondarv  carcinoma  the 
infection  appears  to  have  been  direct.  That- is,  the  cancer  cells 
from  one  growth  have  apparently  passed  down  the  bowel  and 
become  implanted  in  the  mucous  membrane  of  the  colon,  pre- 
sumably through  an  abrasion  or  some  breach  of  surface.  It 
is,  of  course,  possible  that  the  two  growths  have  arisen  separateh', 
and  have  no  connection  with  each  other  ;  but  in  at  least  one  of 
the  cases  the  appearances  suggested  that  the  lower  growth  was 
secondary  to  the  upper  one. 


252  MALIGNANT    DISEASE 

In  a  case  recorded  by  Mr.  C.  ]\Iorton,*  the  cscum  was  excised 
for  cancer,  and  the  ileum  anastomosed  to  the  ascending  colon. 
The  patient  recovered  ;  but  five  years  later  there  was  a  cancer 
in  the  transverse  colon,  and  the  patient  died  after  an  operation 
for  its  removal. 

I  have  found  several  instances  of  more  than  one  growth  in  the 
same  colon  in  different  parts. 

Mr.  Littlewood  recently  reported  two  such  cases,  j  In  one,  the 
patient,  a  woman  aged  52,  had  a  cancer  in  the  splenic  flexure  of 
the  colon,  and  another  in  the  rectum.  In  the  other  case,  a  man 
aged  69  had  a  cancer  in  the  ascending  colon  and  another  similar 
growth  in  the  rectum. 

A  case  of  particular  interest  is  recorded  by  Mr.  G.  Simpson,  + 
in  which  there  were  two  primary  growths  in  the  colon.  One  was 
in  the  caecum  ;  and  on  microscopical  examination  was  found 
to  be  a  columnar-celled  growth  undergoing  colloid  degeneration  ; 
and  the  other  was  in  the  hepatic  flexure,  and  was  a  t\'pical 
scirrhous  cancer  with  numbers  of  irregular  cells  arranged  in 
lines. 

Metastatic  growths  of  the  colon  secondary  to  cancer  in  parts 
of  the  bod\'  other  than  the  alimentary  tract  are  very  uncommon. 
Such  a  case  is,  however,  recorded  by  Mr.  Arbuthnot  Lane.  The 
patient  was  a  woman,  who  many  years  previoush'  had  had  her 
breast  removed  for  cancer.  There  were  no  signs  of  recurrence 
in  the  scar  or  glands,  but  a  growth  in  the  sigmoid  was  detected. 
At  the  operation  a  cancerous  growth  was  found  extending 
from  the  mesentery  into  the  sigmoid  and  stricturing  it.  Other 
growths  were  found  of  a  similar  nature  in  the  rectum  and  in  the 
ascending  colon.  There  was  also  growth  in  the  liver.  The 
whole  colon  was  removed  and  the  ileum  stitched  into  the  anus. 
The  patient  died  three  weeks  later.  It  was  found  that  the 
growths  were  secondary  carcinoma,  and  involved  in  a  varying 
degree  almost  the  whole  colon. 

The  following  remarkable  case  of  several  separate  malignant 
growths  in  the  colon  was  under  m}-  care  at  St.  Mark's  Hospital : 

Case. — The  patient,  a  man  aged  46,  had  a  small  adeno-carcinoma  in 
the  centre  of  his  sigmoid  flexure.  This  was  successfully  resected,  and 
he  remained  apparently  well  for  nine  months,  when  he  was  examined 


*  Brit.  Med.  Jour.,  Oct.  29,  1904.  f  Lancet,  Jan.  11,  1907. 

t  Brit.  Med.  Jour.  Dec.  7,  1907. 


OF    THE    COLON  253 

with  the  sigmoidoscope  because  he  was  again  passing  blood.  It 
was  then  seen  that  he  had  several  large  polypi,  some  six  inches 
or  more  above  the  line  of  the  previous  resection,  the  intervening 
mucous  membrane  being  normal.  One  of  these  polypi  was  removed, 
and  on  examination  was  found  to  be  a  typical  carcinoma.  A  second 
operation  was  performed,  but  the  patient  died  from  peritonitis. 
Post  mortem,  six  of  these  polypi  with  long  slender  stalks  were 
discovered,  the  highest  of  which  was  nine  inches  above  the  growth 
originally  removed.  Two  of  these  were  examined,  and  one  showed 
typical  cancer  formation.  There  were  no  signs  of  secondarv 
deposits  anywhere.  The  only  reasonable  explanation  of  this 
curious  case  seems  to  be  that  the  original  growth  resulted  from  a 
simple  polypus  which  had  become  malignant,  and  that,  later,  the 
remaining  polypi  also  took  on  malignant  change. 

The  Lines  of  Extension  of  the  Growth. — The  study  of 
the  directions  and  ways  in  which  cancer  of  the  colon  extends  is 
of  the  utmost  importance,  for  unless  these  are  known  it  is  not 
possible  to  so  plan  an  operation  as  to  be  reasonably  certain  of 
removing  the  entire  growth.  And  it  is  only  when  operations  for 
cancer  are  planned  according  to  the  known  methods  of  extension 
of  the  growth  that  really  successful  results  can  be  obtained. 

As  already  stated,  cancer  when  it  affects  the  colon  tends  for  a 
long  time  to  remain  localized  to  the  bowel-wall,  and  it  is  excep- 
tional to  find  the  glands  in  the  mesocolon,  and  especially  the 
retro-peritoneal  glands,  involved,  except  in  very  late  cases.  Out 
of  thirty  cases  in  which  glands  were  specially  looked  for,  enlarged 
glands  were  present  in  the  mesocolon  in  only  five,  and  retro- 
peritoneal glands  in  only  three  cases.  In  only  two  cases  was 
there  a  secondary  deposit  in  the  liver.  The  thirty  were  ail 
cases  in  which  an  operation  had  been  performed,  and  not  those 
reaching  the  post-mortem  table  after  dying  from  cancer. 
Of  course,  a  much  higher  proportion  of  secondary  deposits 
would  be  found  if  cases  of  advanced  and  inoperable  disease 
were  taken. 

At  the  stage  when  cancer  of  the  colon  is  usually  detected, 
enlargement  of  the  glands  in  the  root  of  the  mesocolon  and 
behind  the  posterior  peritoneum  is  exceptional,  the  growth 
tending  rather  to  spread  in  the  bowel-wall,  and  to  involve  onh' 
those  glands  in  immediate  contact  with  it.  We  are  too  apt  to 
assume,  because  enlarged  glands  are  found  in  the  neighbourhood 
of  a  mahgnant  growth,  that  they  are  therefore  the  seat  of 
cancer  cells.     Frequenth',  however,  this  is  not  the  case. 


254  MALIGNANT  DISEASE 

Mr.  Clogg,  in  a  similar  investigation,  found  that  in  only  two- 
thirds  of  the  cases  in  which  there  were  enlarged  glands  could 
cancer  cells  be  found. 

While  enlarged  glands  are  not  uncommonly  present  in 
immediate  proximity  to  the  growth,  and  in  the  fat  around  the 
bowel,  they  are  not  very  common  at  the  root  of  the  mesocolon 


Fig.  60. — Cancer  of  the  sigmoid  flexure.  A  transverse  microscopical  section  of  the  colon 
through  the  centre  of  the  growth.  The  gland  in  the  lower  edge  does  not  shoW  any  cancer  cells. 
'J'he  growth  is  spreading  in  the  submucous  layer.  Photograph  from  a  specimen  prepared  by 
Mr.  i.enthal  Cheatle. 

or  in  the  retro-peritoneal  tissue  ;  and  in  many  cases  the  glands 
that  are  enlarged  are  not  cancerous.  While  there  are  certainly 
exceptions,  as  a  rule  cancer  of  the  colon  grows  very  slowly,  and 
seldom  gives  rise  to  secondary  deposits  in  glands  or  other  viscera. 
I  have  seen  a  patient  who  six  years  previously  had  colotomy 
performed   for  cancer   at   the  recto-sigmoidal  junction   (a  piece 


OF    THE    COLON  255 

of  the  growth  was  at  that  time  removed  and  examined 
microscopically) .  and  who  was  still  in  good  health  and  free 
from  an\-  signs  of  secondary  deposits.  Mr.  Swinford  Edwards 
had  a  similar  case,  in  which  the  patient  lived  for  over  five  years 
without  secondary  deposits  forming.  \\'hen  secondary  deposits 
do  occur,  thev  are  invariably  found  in  the  liver,  and  practically 
never  elsewhere  unless  thev  are  also  present  in  the  liver. 

Invasion  of  other  organs,  such  as  the  stomach,  bladder,  and 
small  intestine,  are  not  uncommon,  but  these  do  not  come  under 
the  head  of  secondary  deposits. 

Though  cancer  of  the  colon  does  not,  as  a  rule,  spread  rapidly, 
and  but  seldom  'causes  secondar\-  deposits,  its  victims  do  not 
often  Hve  long,  as  it  soon  produces  obstruction,  and,  if  un- 
operated  upon,  a  quite  small  and  localized  growth  will  bring 
about  a  fatal  result  in  a  very  few  months.. 

Cancer  of  ths  IleoccBcal  Angle. — This  is,  next  to  the  sigmoid 
flexure,  the  commonest  situation  for  cancer  of  the  colon. 
The  commonest  situation  for  the  growth  to  start  is  at  the  ileo- 
caecal  valve  ;  other  situations  being  on  the  posterior  csecal  wall, 
at  the  junction  of  the  caecum  and  ascending  colon,  and  in  the 
appendix. 

Cancer  of  the  Transverse  Colon. — Growths  in  this  situation 
tend  very  soon  to  involve  the  stomach.  Out  of  eight  cases  of 
cancer  of  the  transverse  colon  of  which  I  have  notes,  four  had 
spread  to  the  stomach,  and  in  two  a  fistula  communicated 
between  the  colon  and  stomach. 

Cancer  of  the  Sigmoid  Flexure. — This  may  occur  in  any 
part  of  the  sigmoid  flexure  ;  but  the  commonest  situations  are 
at  about  its  centre, — that  is  to  say,  at  the  apex  of  the  loop  and 
at  the  recto-sigmoidal  junction. 

Symptoms. 

These  are  most  variable,  and  depend  upon  a  number  of 
factors,  such  as  the  type  and  stage  of  the  disease,  the  situation, 
and  the  condition  of  the  patient.  So  greatly  do  the  symptoms 
var\-  in  different  cases,  that  we  might  almost  say  that  any 
s\'mptom  referable  to  the  colon  may  be  produced  b\-  cancer. 

None,  unfortunately,  are  characteristic.  As  a  rule,  they 
are  at  first  those  of  an  irritative  lesion  in  the  colon,  and 
later  of  a  stenosis.  A  growth  may  exist  in  the  colon  for 
long  periods  without  producing  any  symptoms  of  importance, 


2=^6 


MALIGNANT    DISEASE 


or  causing  the  patient  any  serious  inconvenience.  Often  the 
earliest  sign  is  some  irregularity  in  the  action  of  the  bowels. 
There  mav  be  shght  attacks  of  diarrhoea,  occurring  fairly  fre- 
quently and  without  any  apparent  cause  ;  or,  on  the  other  hand, 


Fig.  6i. — Tumour  high  up  in  the  sigmoid  flexure  (sigmoidoscopic). 

the  bowels,  which  had  previously  been  regular,  have  a  tendency 
to  become  constipated,  and  occasional  aperients  are  required. 
Sometimes  again,  the  first  sjTnptom  is  the  presence  of  mucus 
m  the  stools,  either  as  slime  or  casts,  and  accompanied  b}-  slight 


Fig.  62. — Malignant  growth  at  the  lower  end  of  the  sigmoid  flexure 
growing  from  the  anterior  bowel-wall  (sigmoidoscopic). 

diarrhoea.  Such  cases  are  usually  first  diagnosed  as  chronic 
colitis  ;  and  I  have  seen  seven  such  cases  which  proved  on 
examination  to  be  cancer  of  the  pelvic  colon.  Pain  or  discomfort 
in   the  abdomen  is  often   an  early  svmptom.     The  pain  may 


OF    THE    COLON  257 

either  take  the  form  of  occasional  attacks  of  colic,  or  of  a 
more  or  less  constant  sense  of  abdominal  discomfort,  often 
described  as  a  dull,  dragging  pain.  Flatulence,  requiring  the 
constant  passage  of  wind,  is  another  early  symptom  in  some  cases. 

I  recently  saw  a  patient  who  complained  of  slight  colicky  pain 
coming  on  in  the  afternoon  after  he  had  been  standing  for  some 
time,  and  the  presence  of  mucus  in  the  stools.  These  symptoms 
had  begun  about  nine  months  previously  as  the  result  of  an 
attack  of  indigestion.  There  were  no  other  symptoms,  and  the 
patient  looked  in  excellent  health  ;  but  a  sigmoidoscopic  examin- 
ation revealed  a  cancerous  ulcer  in  the  sigmoid  flexure.  I  once 
saw  a  case  in  which  the  first  symptom  of  a  growth  in  the  sigmoid 
flexure  was  a  sudden  and  severe  haemorrhage  from  the  rectum  ; 
but  this  is  unusual.  As  a  rule,  bleeding  is  conspicuous  by  its 
absence  in  the  early  stages  of  cancer  of  the  colon.  The  onset  of 
symptoms  is  often  quite  abrupt,  and  may  be  attributed  by  the 
patient  to  some  dietary  indiscretion. 

It  is  obvious  that  the  symptoms  just  detailed  are  so  compara- 
tively insignificant,  and  so  common  as  the  result  of  other  and  less 
important  conditions,  that  it  is  improbable  they  should  give  rise 
to  any  suspicion  of  cancer  of  the  colon.  Certainly  no  one  would 
venture  to  make  a  diagnosis  of  growth  upon  such  evidence. 
Nevertheless,  they  are  of  the  utmost  importance,  for  if  we  are 
to  treat  cancer  of  the  colon  successfully,  we  must  be  able  to 
diagnose  the  condition  while  the  growth  is  in  its  earliest  stage. 
When  such  symptoms  are  complained  of,  the  patient  should  be 
carefully  examined,  if  possible  with  the  sigmoidoscope,  as  by 
this  means  the  growth  can  often  be  detected  at  quite  an  early 
stage,  when  removal  will  be  successful. 

In  the  later  stages  the  symptoms  are  more  definite.  Pain  is 
more  or  less  constant.  It  may  take  the  form  of  occasional 
sharp  attacks  of  colic,  or  be  of  a  dull,  constant  character.  When 
the  growth  is  in  the  caecal  region,  the  time  at  which  the  pain 
comes  on  sometimes  bears  a  relationship  to  meals,  being  worse 
some  three  or  four  hours  after  food.  When  in  the  pelvic  colon 
it  may  have  a  relationship  to  defaecation. 

The  pain  is  as  a  rule  not  well  localized,  but  occasionally  may 
be.  Sometimes  the  patient  is  conscious  of  an  obstruction  at 
some  part  of  the  colon,  and  will  state  that  he  feels  there  is 
difficulty  in  the  passage  of  the  bowel  contents  past  a  certain 
point. 

17 


25^ 


MALIGNANT    DISEASE 


Constipation  occurs  almost  always,  sooner  or  later.  At  first 
this  is  easil\-  relieved  b\-  aperients  ;  but  later,  aperients  bring 
on  pain,  or  cause  diarrhoea.  As  a  rule,  irregularity  of  the  bowels 
is  the  condition  which  first  occurs,  and  later  obstruction.  Some- 
times complete  obstruction  is  the  first  s\Tnptom  noticed.  In 
some  others  it  is  an  attack  of  partial  obstruction  due  to  faecal 
impaction.  This  is  relieved  satisfactorily  by  aperients  or 
enemata,  and  often  the  true  cause  of  the  condition  is  missed.  All 
cases  of  faecal  impaction  should  be  carefull}'-  examined,  as  the 
condition  usually  results  from  slight  stricturing  of  the  bowel. 

As  already  mentioned,  diarrhoea  is  often  an  earl\-  sjmiptom, 
and  may  also  occur  in  the  later  stages.  It  is,  however,  spurious, 
and  careful  enquiry  wiU  ehcit  the  fact  that  but  httle  is  passed. 


Fi^.  63. — Sudden  narrowing  of  the  bowel  just  below  a  growth  in  the  sigmoid  fle.xure. 
(The  growth  was  adherent  in  the  left  iliac  fossa.)    (Sigmoidoscopic. ) 


It  is  due  to  the  irritation  set  up  by  the  growth  and  by  the  faeces 
retained  above  it.  Occasionally  diarrhoea  is  a  very  marked 
feature  of  the  condition. 

Blood  in  the  stools  is  seldom  present  in  the  earh*  stages,  and 
in  many  cases  is  absent  throughout.  Although  it  is  the  exception 
to  see  blood  in  the  stools,  a  careful  microscopical  examination 
wiU  usuaUv  reveal  the  presence  of  a  few  blood  corpuscles. 

There  are  two  s\-mptoms  which  are  often  mentioned  as  of 
importance,  namety,  loss  of  weight  or  cachexia,  and  ribbon 
or  pipe-stem  faeces.  Neither  of  these  is,  however,  of  any  im- 
portance or  diagnostic  value.  Loss  of  weight  only  occurs  in  the 
late  stages  when  there  is  a  large  growth,  or  when  diarrhoea  is  a 
prominent  symptom  ;    and  it  is  commoner  in  other  conditions 


OF    THE    COLON 


259 


than  in  cancer.  Pipe-stem  faeces  can  only  occur  in  rectal 
cancer  when  the  growth  involves  the  anus,  as  it  is  obvious 
that  the  fasces  will  take  their  shape  from  the  last  orifice  through 
which  they  pass,  and  that  even  if  the  faeces  became  narrowed 
in  passing  a  stricture  in  the  colon,  they  would  be  re-moulded  in 
the  rectum. 

In  a  few  instances  the  first  thing  to  draw  attention  to  the 
growth  is  the  presence  of  a  tumour  in  the  abdomen.  This  is  more 
often  the  case  when  the  growth  is  in  the  caecal  region,  as  here 


Fig.  64.— An  adeno-carcinomatous  polypus  of  the  pelvic  colon.  From  a  specimen  of  the 
author's.  The  polypus  was  detected  by  the  sigmoidoscope,  and  later  resected,  together  with 
two  inches  of  the^colon  ;  the  ends  being  anastomosed.     {Natural  size.) 


a  growth  may  reach  a  considerable  size  before  any  symptoms 
sufficient  to  draw  the  patient's  attention  to  his  condition  have 
arisen.  Although  it  is  fairly  easy  to  make  a  diagnosis  of  cancer 
of  the  colon  when  a  palpable  tumour  is  present,  it  is  of  the  utmost 
importance  that  the  diagnosis  should,  if  possible,  be  made  before 
this,  as  by  the  time  a  tumour  has  reached  a  sufficient  size  to  be 
palpable  the  best  time  for  its  removal  has  probably  passed. 
It  cannot  be  too  strongly  emphasized  that  if  cancer  of  the 


26o  MALIGNANT    DISEASE 

colon  is  to  be  successfully  treated,  it  is  necessary  that  patients 
should  be  carefully  examined  directly  there  are  any  symptoms 
the  least  suspicious  of  that  condition. 

Secondary  Results  of  Cancer  of  the  Colon. — Intestinal 
obstruction  is  by  far  the  commonest  of  these,  and  may  be  said 
to  occur  in  almost  all  cases.  It  is  often  the  symptoms  of  obstruc- 
tion which  first  call  attention  to  the  disease.  The  obstruction 
is  never  complete,  and  there  is  always  a  slight  lumen  which  will 
allow  fluid  contents  to  pass.  In  many  cases  it  remains  partial 
for  a  long  period,  giving  rise  to  the  typical  symptoms  of  chronic 
obstruction,  and  resulting  in  hypertrophy  and  dilatation  of  the 
bowel  above  the  stricture.  Sooner  or  later,  however,  the  narrow 
opening  becomes  blocked,  either  from  a  hard  mass  of  faeces  or  a 
foreign  body  becoming  impacted  in  it,  and  acute  obstruction 
then  sets  in.  This  may  also  result  from  a  kink  occurring  as  the 
result  of  the  growth  having  become  adherent  to  some  other 
organ  or  structure,  or  owing  to  the  mesentery  becoming  shortened 
from  contraction  of  the  fibrous  tissue  about  the  growth.  Acute 
obstruction  may  also  occur  from  intussusception  started  by  a 
growth  in  the  colon.  The  late  Mr.  Barnard  found  five  cases  of 
this  condition  in  the  records  of  the  London  Hospital. 

Ulceration  of  the  growth  does  not  occur  at  so  early  a  stage  of 
the  disease  as  in  the  case  of  rectal  cancer,  probably  owing  to  the 
fact  that  the  colon  is  not  so  subjected  to  injury  from  the  passage 
of  hard  faecal  masses. 

Spontaneous  anastomosis  occurred  in  three  of  the  cases  in  my 
series.  In  two,  the  transverse  colon  communicated  with  the 
stomach,  and  in  the  other  with  the  ileum.  Tuttle  operated  upon 
two  cases,  in  one  of  which  the  sigmoid  communicated  with  the 
ileum  near  its  termination  ;  and  in  the  other  the  two  extremities 
of  the  sigmoid  flexure  communicated  with  each  other  and  short- 
circuited  the  central  portion. 

As  a  rule  the  anastomosis  is  only  a  small  opening,  but  some- 
times it  is  large  enough  to  allow  most  of  the  intestinal  contents 
to  be  short-circuited. 

The  two  parts  of  bowel  first  become  adherent  at  the  base  of 
the  growth  ;  and  then  the  growth  extends  into  the  walls  of  the 
adherent  viscus.  Later,  ulceration  occurs,  and  the  blood- 
supply  being  poorest  in  the  central  portion  a  communication 
is  established  between  the  two.     In  a  few  cases,  however,  the 


OF    THE    COLON 


261 


communication  occurs  differently.  The  growth  in  the  colon 
becomes  ulcerated,  the  ulcer  perforates  the  bowel-wall,  and  a 
pericolic  abscess  forms,  communicating  by  the  ulcer  with  the 
colon.  This  abscess  then  becomes  adherent  to  some  other 
viscus,  such  as  the  stomach  or  ileum,  and  eventual^  bursts 
into  it  and  establishes  a  communication  between  it  and  the 
colon  bv  wa\-  of  the  abscess. 


-—^—.^-42^ 


Fig.  65. — Diagrams  illustrating  different  ways  in  which  spontaneous  anastomosis  may  result 
from  a  malignant  growth  in  the  colon.  I. — Anastomosis  between  stomach  and  transverse  colon. 
II. — Anastomosis  between  ileum  and  sigmoid  flexure.  III. — Anastomosis  between  ileum  and 
transverse  colon.  IV. — Anastomosis  between  two  loops  of  sigmoid  fle.xure.  V. — Anastomosis  by 
abscess  formation  between  stomach  and  transverse  colon. 

Malignant  peritonitis  is  very  rare  as  a  complication  of  cancer 
of  the  colon. 

Acute  dilatation  of  the  colon  may  occur  above  a  malignant 
stricture.  The  dilatation  may  involve  the  colon  immediately 
above  the  stricture,  or  may  affect  the  caecum  only.  Thus,  the 
stricture  may  be  in  the  sigmoid  flexure,  and  the  colon  between 
this  and  the  caecum  may  be  almost  normal,  and  yet  extreme 
dilatation  of  the  caecum  may  be  found.  This  is  generally  a 
terminal  and  fatal  compHcation. 


262  MALIGNANT    DISEASE 

Fatal  Termination  in  Cancer  of  the  Colon. — Cancer  of 
the  colon  seldom  kills  directh-^,  or  even  so  directly  as  cancer  of 
most  other  organs.  The  fatal  termination  may  occur  from  one 
of  several  secondary  consequences.  It  may  be  from  acute 
intestinal  obstruction  ;  from  a  toxaemia  due  to  the  absorption 
of  poisons  in  the  foul  bowel  contents  retained  above  the 
stricture  ;  from  acute  peritonitis  consequent  upon  a  perforating 
ulcer  in  the  dilated  bowel  above  the  growth  ;  or  from  extensive 
suppuration  due  to  perforation  of  the  growth  or  of  an  ulcer 
in  the  bowel  above  it. 

Sarcoma  of  the  Colon. — This  is  a  ver}^  rare  form  of  disease 
of  the  colon,  and  I  have  onty  been  able  to  find  seven  cases  of  the 
condition.  As  one  would  expect,  the  patients  are  j^ounger  as  a 
rule  than  is  the  case  with  cancer. 


le  ages  in  these  seven  cases  were  as  follows  : — 

I.  Male,       age  17 

5.  Male,         age  8 

2.  Female      ,,    50 

6.  Female       ,,    not  stated 

3.  Male           ,,    12 

7-       >'            ..      5 

4.  Female      ,,    21 

In  all  these  seven  cases  the  growth  was  in  the  csecal  region. 
It  is  generally  a  fusiform-celled  sarcoma,  but  in  one  case  it 
was  myxo-sarcoma,  and  in  one  a  fibro-sarcoma.  Sarcoma  differs 
markedly  from  cancer  in  appearance,  as  it  looks  as  if  it 
had  invaded  the  bowel-w^all  from  outside.  The  mucous  mem- 
brane is  at  first  intact,  and  is  stretched  over  the  tumour.  It 
originates  in  the  interstitial  tissues  of  the  bowel-wall,  and 
tends  to  spread  along  the  submucous  and  subperitoneal  laj'ers, 
both  circularly  and  longtitudinally.  In  cut  sections  these  two 
layers  are  seen  to  be  greatl}^  thickened  and  to  consist  entirely 
of  sarcomatous  tissue.  The  growth  does  not  affect  the  mucous 
membrane  earty,  and  it  does  not  tend  to  ulcerate  into  the  bowel 
lumen.  There  was  no  ulceration  in  an 3^  of  these  seven  cases. 
In  some,  the  growth  seems  to  spread  along  the  bowel,  forming  a 
tubular  stricture,  and  forms  outgrowths  or  tumours  under  the 
peritoneum  ;  while  in  others  it  tends  rather  to  spread  into  the 
bowel  and  form  a  large  tumour  filling  up  the  lumen. 

The  growth  may  apparenth;^  start  in  the  subperitoneal  layer, 
and  in  one  patient  almost  the  whole  growth  was  outside  the 
muscular  coat.  It  appears  to  originate  in  the  neighbourhood 
of  the  ileocaecal  valve,  but    there  is  nothing  to  show  exactly 


OF    THE    COLON  263 

where  it  started.     Marked  ascites   due    to    involvement  of  the 
peritoneum  was  present  in  one  of  the  cases. 

Treatment  of   Cancer  of  the  Colon. 

Cancer  of  the  colon  can  be  very  successfully  treated  by  opera- 
tion, and  excellent  results  can  be  obtained  as  regards  both  the 
subsequent  comfort  of  the  patient  and  freedom  from  future 
recurrence  of  the  tumour. 

As  has  already  been  pointed  out,  growths  of  the  colon  tend  to 
remain  locahzed  to  the  bowel-wall  for  a  long  time,  and  do  not 
readily  give  rise  to  secondary  gland-involvement  in  the  root  of 
the  mesentery  or  posterior  peritoneal  chain  of  glands.  They 
grow  slowly,  and  but  seldom,  and  only  in  their  later  stages,  give 
rise  to  metastatic  deposits  in  other  parts  of  the  body.  They  do 
not  readily  become  adherent  to  important  organs,  though  an 
exception  to  this  statement  must  be  made  in  the  case  of  growths 
of  the  transverse  colon,  which  frequently  involve  the  stomach. 
Large  portions  of  the  colon  can  be  removed  without  causing  the 
patient  any  serious  subsequent  inconvenience,  or  preventing 
him  from  enjoying  life. 

The  operation  for  excision  of  a  cancer  of  the  colon  does  not  as  a 
rule  present  any  very  serious  difficulties,  and  there  are  many 
different  methods  of  dealing  with  the  bowel,  after  the  growth 
has  been  excised,  which  can  be  adopted  according  to  the  exi- 
gencies of  the  case. 

The  most  important  factor,  as  in  cancer  anywhere  else  in  the 
body,  is  early  diagnosis.  Our  methods  of  diagnosing  cancer  of 
the  bowel  have  much  improved  in  recent  years,  and  it  is  now  the 
exception  for  a  growth  to  reach  a  large  size  before  it  is  recognized. 
Perhaps  fortunately,  cancer  of  the  colon  draws  attention  to 
itself  at  an  early  stage  by  producing  obstruction. 

In  many  cases  cancer  is  first  detected  at  an  operation  under- 
taken for  the  relief  of  obstruction.  It  will  therefore  be  necessary 
to  consider  first  the  methods  of  deahng  with  cases  of  obstruction 
of  the  colon  due  to  cancer,  and  then  to  consider  the  treatment  of 
the  growth  itself.  The  actual  details  of  the  different  operations 
are  considered  separately,  and  I  shall  deal  here  only  with  the 
indications  for  operation  and  the  choice  of  methods. 

The  Treatment  of  Obstruction  due  to  Cancer  of  the 
Colon. — Most  cases  of  cancer  of  the  large  bowel  present  them- 
selves to  the  surgeon  with  symptoms  of  obstruction  either  acute 


264  MALIGNANT    DISEASE 

or  chronic.  When  there  is  acute  obstruction,  the  obvious  indica- 
tions are  to  relieve  the  obstruction,  which  immediately  threatens 
a  fatal  issue,  rather  than  to  excise  the  growth,  which  may  be 
dealt  with  afterwards,  and  at  any  rate  can  only  be  directly 
fatal  at  some  later  date.  The  surgeon  should  not  be  tempted 
into  doing  a  complete  operation,  which,  though  it  may  be  ideal 
in  theory,  is  in  practice  too  often  attended  by  fatal  consequences. 

Patients  with  acute  obstruction  of  the  colon  are  generally  in 
a  profound  toxemic  condition  owing  to  the  accumulation  of 
poisonous  substances  in  the  large  bowel,  and  are  not  in  a  state 
to  stand  any  but  the  simplest  and  briefest  of  operations.  More- 
over, to  excise  the  growth  and  anastomose  the  ends  in  a  patient 
with  acute  obstruction,  is  to  leave  the  patient  with  a  newly- 
formed  joint  in  the  bowel  which  will  certainly  be  subjected 
almost  immediately  to  the  pressure  of  the  accumulated  contents 
of  the  bowel  above  the  previous  stricture,  and  this  is  putting 
more  strain  upon  the  surgeon's  handiwork  than  is  at  all  justifi- 
able. When  there  is  chronic  obstruction,  but  the  symptoms 
are  not  acute,  the  choice  of  method  must  depend  upon  whether 
it  is  possible  entirely  to  empty  the  bowel  above  the  stricture. 
If  it  is  possible  by  means  of  aperients  to  satisfactorily  empty  the 
bowel,  and  the  surgeon  is  certain  that  there  is  no  accumulation 
of  faecal  material  above  the  growth,  then  resection  of  the  growth 
and  immediate  end-to-end  or  lateral  anastomosis  of  the  bowel 
would  seem  justifiable. 

But  if  the  bowel  cannot  be  so  emptied,  the  case  should  be 
treated  in  the  same  way  as  if  acute  obstruction  existed.  This, 
though  it  entails  the  patient  undergoing  at  least  two  operations, 
is  infinitely  safer  than  performing  an  anastomosis  with  accumu- 
lated faeces  above  the  line  of  suture. 

I  have  collected  a  large  number  of  cases  with  the  view  of 
ascertaining  the  safest  methods  of  deahng  with  cases  of  cancer 
of  the  colon,  and  for  this  purpose  have  taken  only  those  in  which 
the  growth  has  been  removed  either  at  the  first  or  at  some  subse- 
quent operation,  and  have  divided  these  into  groups  according 
to  the  method  adopted  in  each  case. 

Cases  of  Immediate  Excision  of  the  Growth,  with  Anastomosis  of 
THE  Bowel,  either  end-to-end  or  laterally,  by  Suture. 

^  n  •  J  r>  J  Percentage 

Cases.  Dud.  Recovered.  Mortality. 

86  32  54  37 

Six  cases  recovered  with  a  faecal  fistula. 


OF    THE    COLON  265 

Cases  of  Immediate  Excision  with  Anastomosis  by  Mlrphy's 
Button. 

Cases.  Died.  Recovered.  ^i[^^. 

18  7  II  38 

Immediate  Excision  of  the  Growth,  the  Ends  of  the  Bowel  being 
brought  out  of  the  Abdomen  and  an  Artificial  Anus  estab- 
lished. Followed  later  by  end-to-end  Anastomosis  or 
Destruction  of  the  Spur  (Paul's  Method). 

Cases.  Died.  Recovered.  ^S 

23  4  19  17 

Cases  in  which  an  Artificial  Anus  was  made  and  Excision  of  the 
Growth  performed  later. 

Cases.  Died.  Recovered.  ^f"'1"/^ 

Mortality. 

505  nil. 

Mo3Tiihan's  figures  in  his  book  on  operations  on  the  abdomen 
give  similar  results  ;   they  are  : — 

Immediate  excision  and  anastomosis — 3  cases  with  i  death. 

Paul's  operation — 12  cases  with  i  death. 

Colotomy  followed  by  excision — 17  cases  with  3  deaths. 

The  above  figures  show  that,  while  excision  with  immediate 
anastomosis  is  the  most  popular  method,  it  is  attended  with 
by  far  the  highest  mortality. 

The  figures  indicate  that  colotomy  followed  by  excision  is 
safer  than  excision  and  bringing  the  ends  out  ;  but  several  of 
the  cases  in  m\^  tables  were  not  done  by  Paul's  operation  with 
glass  tubes.  It  seems  probable,  therefore,  that  both  methods 
are  about  equalh"  satisfactory  as  regards  a  low  mortality. 

Immediate  excision  and  anastomosis  is  attended  by  more 
than  double  the  mortality  of  the  operations  in  which  an  artificial 
anus  is  established  ;  and  in  spite  of  its  obvious  advantages  it 
should  certainly  not  be  performed  except  where  the  bowel  can 
be  completely  emptied.  The  fact  that  a  faecal  fistula  occurred 
in  several  of  the  cases  that  did  recover,  shows  that  the  hne  of 
suture  did  not  hold,  and  that  the  patient  had  run  a  very  serious 
risk  of  losing  his  Hfe. 

Paul's  operation,  in  which  the  growth  is  excised  at  the  first 
operation,  and  the  two  ends  of  the  bowel  are  brought  out  and 
glass  tubes  tied  into  them  to  form  an  artificial  anus,  has  the 
obvious  advantage  over  colotomy  followed  by  excision,  that  the 


266  MALIGNANT    DISEASE 

growth  is  removed  at  the  earhest  possible  time.  It  does  not, 
however,  save  the  patient  from  a  subsequent  operation,  as  a 
secondar}^  operation  to  close  the  artificial  anus  will  almost  cer- 
tainh^  be  necessary.  In  the  case  of  colotomy  followed  by 
excision  of  the  growth,  three  operations  may  be  necessary,  the 
third  being  done  to  close  the  artificial  anus  after  the  growth  has 
been  excised  and  the  continuity  of  the  bowel  restored.  The 
third  operation  may  be  avoided  b}-  closing  the  artificial  anus 
at  the  second  operation  ;  this,  however,  considerabh^  increases 
the  risk  of  the  second  operation.  One  objection  to  Paul's  method 
is,  that  if  the  growth  is  to  be  excised  properly,  together  with  its 
l^rmphatic  area,  the  operation  will  in  many  cases  take  some  time 
to  perform.  This  sometimes  renders  it  unsuitable  where  acute 
obstruction  exists  at  the  time.  Also,  it  is,  of  course,  only  possible 
where,  after  excision  of  the  growth,  the  two  ends  of  the  bowel 
can  easily  be  brought  up  to  the  surface. 

An  operation  for  cancer  of  the  colon  should  aim  at  excising. 
not  onlv  the  growth,  but  also  the  whole  of  the  lymphatic  area 
in  the  mesentery,  and,  if  possible,  the  chain  of  glands  in  the  root 
of  the  mesenterj;'  and  along  the  vessels  passing  to  the  affected 
portion  of  bowel.  This  is  not  a  very  difficult  matter  in  most 
parts  of  the  colon,  but  it  often  necessitates  the  sacrifice  of  a 
considerable  length  of  gut  in  order  to  make  certain  that  the 
blood-supply  to  that  left  behind  is  good.  A  large  wedge-shaped 
piece  of  mesocolon  should  be  removed,  and  the  peritoneum  at 
the  back  of  the  abdomen  stripped  up  sufficiently  to  allow  the  fat 
and  glands  to  be  cleared  out. 

As  I  have  already  shown  in  discussing  the  pathology,  growths 
of  the  colon  spread  round  the  bowel-wall  and  up  and  down  in  the 
submucous  layers,  and  cancer  cells  frequently  appear  in  this 
layer  at  some  little  distance  from  the  apparent  edge  of  the 
growth.  Operations,  therefore,  in  which  the  growth  is  excised 
but  the  bowel  is  not  resected,  or  in  which  the  bowel  is  cut  close 
to  the  growth,  are  more  than  likely  to  fail  in  eradicating  the 
disease.  The  entire  circumference  of  the  bowel  should  always 
be  removed,  and  the  gut  be  divided  at  least  an  inch,  and  if 
possible  more,  from  the  extreme  hmits  of  the  growth  both  above 
and  below. 

Another  plan  for  deaUng  with  growths  in  the  colon  must  be 
mentioned,  namely  by  immediate  short-circuit  of  the  growth  by 
lateral  anastomosis,  foUoM^ed  later  by  excision  and  closure  of  the 


OF    THE    COLON  267 

ends.  This  method  is  certainly  inferior  to  those  previously  men- 
tioned. 

Indications  for  Removing  the  Growth. — It  is  too  often 
supposed  that  because,  on  opening  the  abdomen,  the  growth  is 
found  to  be  large  or  to  be  accompanied  by  a  number  of  enlarged 
glands,  it  is  therefore  useless  to  remove  it.  In  discussing  the 
pathology  it  was  pointed  out  that  cancer  of  the  colon  tends  to 
remain  localized  for  long  periods,  and  that  the  enlarged  glands 
are  frequently  not  cancerous  ;  they  do  not,  therefore,  necessarily 
mean  that  the  tumour  has  passed  beyond  the  stage  of  successful 
removal,  or  that  if  the  glands  cannot  all  be  removed,  rapid 
recurrence  will  necessarily  foUow.  Even  adhesions  are  often 
not  cancerous,  and  if  the  tumour  can  be  removed  and  the  con- 
tinuity of  the  bowel  ultimately  restored  without  very  serious 
risk,  the  operation  should  most  certainly  be  proceeded  with. 

There  are  several  instances  in  which  there  were  enlarged 
glands  in  the  mesocolon  at  the  time  of  operation,  and  yet  the 
patient  did  not  develop  any  signs  of  recurrence  of  the  growth. 
Mr.  Charters  Symonds  records  a  case  in  which  enlarged  glands 
were  left  in  the  mesocolon,  but  the  patient  remained  free  from 
recurrence  ten  years  later. 

Paul  records  two  cases.  One,  in  which  glands  as  large  as 
filberts  were  present  in  the  root  of  the  mesentery,  was  well  and 
free  from  recurrence  five  years  after  excision  of  the  growth.  In 
the  other  case  there  were  also  many  enlarged  glands,  but  the 
patient  was  free  from  recurrence  two-and-a-half  years  after  the 
operation. 

Adhesions  of  the  growth  to  other  viscera  should  also  not 
necessarily  be  considered  as  contraindicating  excision,  unless 
the  adhesions  are  to  some  part  which  cannot  be  removed.  If 
they  are  to  the  stomach,  a  portion  of  the  latter  viscus  can  be 
excised  with  the  tumour.  I  know  two  cases  in  which  this  was 
successfully  done.  Similarly,  if  the  ileum  is  involved,  a  portion 
of  it  can  be  resected.  In  the  case  of  adhesions  to  the  abdominal 
wall,  there  is  no  great  difficulty  in  removing  the  affected  portion, 
providing  it  is  not  too  extensive. 

Excision  of  Growths  in  the  Ccscal  Region.— -These  lend  them- 
selves readily  to  extensive  resection,  as  the  entire  csecal  angle 
of  the  colon  can  be  freed  and  removed  together  with  the 
growth.  Any  attempts  to  resect  portions  of  the  caecum  will 
probably  end  in  failure,  both  as  regards  removal  of  the  disease, 


268  MALIGNANT    DISEASE 

and  also  satisfactory  restoration  of  the  parts.  The  peritoneum 
attaching  the  caecum  and  ascending  colon  to  the  posterior 
abdominal  wall  should  be  divided  on  each  side,  and  the  entire 
caecal  angle  stripped  up,  together  with  the  growth  and  tissues  in 
the  iliac  fossa.  Next,  the  vessels  should  be  defined,  care  being 
taken  to  avoid  the  duodenum,  ureter,  and  spermatic  vessels. 
Those  vessels  that  will  require  ligature  are  the  ileocolic  and  caecal 
arteries.  If  there  are  any  glands  along  the  line  of  the  right 
ileocolic  artery,  it  may  be  further  necessary  to  ligature  the  right 
colic  artery  which  lies  close  to  it,  in  order  to  make  certain  of 
clearing  them  away.  The  entire  caecal  angle  and  tumour  can 
now  be  easily  brought  out  of  the  wound.  Clamps  are  next 
applied  to  the  ileum  and  colon,  and  the  tumour  and  caecum  are 
cut  away.  If  it  has  been  necessary  to  ligature  the  right  colic 
artery,  the  greater  part  of  the  ascending  colon  must  also  be 
removed,  as  its  blood-supply  has  been  damaged. 

The  next  step  is  to  deal  with  the  bowel  ends.  It  is  most  impor- 
tant to  see  that  there  is  a  good  blood-supply  to  the  stump  of 
bowel  left  after  division.  If  this  is  not  satisfactory,  more  bowel 
should  be  resected  until  an  efficient  blood-supply  is  obtained. 

The  choice  of  a  method  must,  of  course,  depend  very  largely 
upon  the  circumstances  of  the  case.  It  will  not  always  be 
possible  to  bring  the  stump  of  the  ascending  colon  sufficiently 
out  of  the  wound  to  establish  an  artificial  anus  by  Paul's  method. 
If,  however,  it  is  possible  to  bring  up  the  stump,  then  a  large 
glass  Paul's  tube  should  be  tied  into  it,  and  a  similar  tube  into 
the  stump  of  the  ileum.  These  two  portions  of  bowel  should 
then  be  stitched  together  over  an  area  of  about  two  inches,  to 
facilitate  the  use  of  an  enterotome  afterwards. 

Should  it  be  decided  to  anastomose  the  bowel  at  once,  there 
are  two  methods  available.  The  stump  of  the  ascending  colon 
can  be  closed  up,  and  the  ileum  implanted  into  its  side  or  into 
the  transverse  colon  ;  or,  the  stumps  may  be  joined  end-to-end 
by  suture,  after  their  respective  openings  have  been  made  to 
correspond  in  size  by  any  of  the  recognized  methods.  There  is 
still  another  method,  namely,  to  close  both  ends  and  do  a  lateral 
anastomosis,  but  this  has  nothing  to  recommend  it,  and  several 
disadvantages. 

Undoubtedly  the  best  procedure  is  to  close  the  end  of  the  colon 
and  implant  the  end  of  the  ileum  into  it.  If  much  of  the  ascend- 
ing colon  has  been  removed  it  will  be  necessary  to  implant  the 


OF    THE    COLON  269 

ileum  into  the  transverse  colon.  Closure  of  the  colon,  and  lateral 
implantation  of  the  ileum  into  it,  can  be  very  rapidly  done,  and 
makes  an  excellent  joint.  Charters  Symonds  in  his  Lett- 
somian  Lectures  in  1908,  advocated  using  a  Murphy's  button 
reinforced  with  Lembert  sutures  to  make  the  anastomosis. 
Stitching",  however,  is  as  quick,  and  certainly  a  preferable  method. 

End-to-end  anastomosis  is  more  difficult,  only  applicable  in 
some  cases,  and  much  more  hable  to  failure,  while  it  does  not 
seem  to  have  any  advantages  over  lateral  implantation. 

Owing  to  the  fluid  nature  of  the  contents  of  the  ileum,  imme- 
diate anastomosis  is  much  safer,  even  when  obstruction  is 
present,  in  cases  of  caecal  cancer  than  in  cancer  of  the  descending 
or  pelvic  colon. 

In  my  collected  cases  there  were  sixty-five  cases  of  excision  of 
the  csecum  for  cancer,  with  nineteen  deaths  from  the  operation. 

Cancer  of  the  Hepatic  Flexure. — Excision  of  growths  of  the 
hepatic  flexure  is  not  often  possible,  because,  there  being  as  a 
rule  no  mesentery,  the  growth  early  becomes  adherent  posteri- 
orly. In  my  series  there  is  only  one  instance  of  successful 
resection  of  a  growth  of  the  hepatic  flexure,  and  in  this  case 
there  was  rapid  recurrence. 

Cancer  of  the  Transverse  Colon. — Excision  of  growths  in  this 
situation  is  not  especially  difficult,  as  this  portion  of  the 
colon  can  be  drawn  out  of  the  abdominal  cavity.  In  my  series 
there  are  five  cases  of  excision  of  a  growth  in  the  transverse  colon. 
In  one,  an  artificial  anus  was  first  established  above  the  growth, 
and,  later  on,  the  growth  was  excised  and  the  bowel  joined  by 
sutures ;  the  patient  recovered.  In  one  case  Paul's  method 
was  adopted  ;  and  in  the  three  others  the  growth  was  excised, 
and  the  colon  joined  end-to-end  by  sutures  at  once.  In  two  of 
the  cases  the  stomach  was  involved  in  the  growth,  and  an  ellip- 
tical portion  of  this  viscus  was  excised,  together  with  the  growth. 
Four  recovered.  The  case  that  died  was  one  in  which  immediate 
end-to-end  anastomosis  was  performed.  In  another  of  the  cases 
of  immediate  end-to-end  union,  a  faecal  fistula  formed  after 
the  operation. 

Cancer  of  the  Splenic  Flexure — There  are  two  cases  in  which 
excision  was  performed.  In  one  the  bowel  was  anastomosed 
end-to-end  by  suture  ;  the  patient  died.  In  the  other  the 
transverse  colon  was  united  to  the  sigmoid  flexure;  this 
patient  recovered,  but  a  feecal  fistula  formed. 


270  MALIGNANT    DISEASE 

Cancer  of  the  Sigmoid  Flexure — In  by  far  the  majority  of  cases 
of  cancer  of  the  colon  the  growth  is  in  the  sigmoid  flexure. 
With  the  exception  of  those  at  the  extreme  lower  end,  these 
growths  may  be  readily  excised,  owing  to  the  mobility  of  this 
part  of  the  colon.  The  sigmoid  flexure  is,  however,  not  so 
suitable  for  end-to-end  anastomosis  after  excision  as  the  caecal 
angle,  owing  to  the  fact  that  the  faecal  contents  are  more  solid, 
and  the  suture  line  will  be  subjected  to  a  greater  strain  after 
operation.  Paul's  operation  is  undoubtedly  the  safest  method 
of  dealing  with  growths  in  this  situation.  The  mortality  from 
it  in  growths  of  the  sigmoid  is  very  low  indeed.  Paul  himself 
has  performed  it  a  great  many  times,  with  only  one  or  two  deaths. 

M.  J.  Boselius  states  that  out  of  twenty-eight  cases  operated 
upon  by  this  method  in  the  Breslau  Hospital  there  were  only 
four  deaths ;  whereas  formerly,  when  end-to-end  union  was 
performed,  the  mortality  was  fifty  per  cent.  Hochenegg  had 
only  one  death  in  fourteen  cases. 

In  my  series  there  are  five  resections  of  the  sigmoid  for  cancer 
with  immediate  end-to-end  anastomosis  ;  of  these,  four  died 
from  the  operation.  Eight  were  treated  by  Paul's  method,  or 
by  the  establishment  of  an  artificial  anus  previous  to  excision, 
and  of  these  none  died.  There  can  be  no  doubt,  therefore,  that 
in  spite  of  the  obvious  disadvantages  of  a  temporary  artificial 
anus  and  of  a  double  operation,  the  best  method  of  dealing  with 
the  bowel  after  excision  of  a  growth  in  the  sigmoid  is  to  bring 
the  ends  out  and  establish  an  artificial  anus,  this  being  subse- 
quently closed  by  a  second  operation.  This  operation  does  not 
incur  much  more  danger  than  a  simple  colotomy.  Colotomy 
above  the  growth,  followed  by  excision,  has  the  serious  disadvan- 
tage that  there  is  considerable  danger  of  not  getting  the  surface 
of  the  abdomen  clean  enough  for  the  second  operation,  and  a 
risk  of  soiling  the  peritoneum  during  its  performance. 

In  excising  a  growth  of  the  sigmoid  flexure  care  should  be 
taken  to  go  well  wide  of  the  growth  (at  least  an  inch  on  each  side 
of  it,  and  preferably  more),  and  to  make  a  clean  sweep  of  the 
mesocolon  containing  the  lymphatics,  and  the  portion  of  bowel 
in  which  the  tumour  is  situated.  The  peritoneum  can  be 
stripped  up  over  the  iliac  vessels  if  necessary,  and  any  glands  in 
this  situation  removed.  The  glands,  if  present,  will  probably  be 
found  lying  close  to  the  sigmoid  and  inferior  mesenteric  arteries. 
Mr.  Moynihan  states  that  there  is  always  a  gland  situated  on  the 


OF    THE    COLON 


271 


inferior  mesenteric  artery,  and  that  the  greater  part  of  the 
sigmoid  loop,  the  mesocolon,  and  the  inferior  mesenteric  artery 
must  be  removed  entirely.  This  makes  the  operation  a  very 
extensive  one,  and,  although  it  has  been  shown  that  after  ligature 
of  the  inferior  mesenteric  artery  there  is  still  an  adequate  blood- 
supply  to  the  parts  that  remain,  such  an  extensive  operation 
seems  hardly  necessary  in  all  cases  in  view  of  the  fact  that  other 
observers  have  not  found  this  enlarged  gland  on  the  vessel  to  be 
by  any  means  invariably  present.  The  presence  of  glands  along 
the  inferior  mesenteric  artery  should  be  looked  for,  and  such 


Fig.  66. — A,  Inferior  mesenteric  artery  ;  B,  ligature  without  destroying  anastomosis  ;  C,  ligatures 
breaking  the  anastomosis.     [Jamieson  and  Dobson,  Proc.  Ro^/.  Soc.  Med.,  Vol.  2,  1909.] 

extensive  removal  only  carried  out  if  they  are  discovered, 
though,  even  when  enlarged,  it  does  not  necessarily  follow  that 
the  gland  is  carcinomatous. 

Considerable  difficulty  exists  when  the  growth,  as  is  not  infre- 
quently the  case,  is  situated  just  above  the  recto-sigmoidal 
junction.  When  the  growth  is  here  it  will  be  so  deeply  situated 
in  the  pelvis  that  considerable  difficulty  may  be  experienced  in 
removing  it ;  but  by  using  the  Trendelenburg  position,  and 
freely  incising  the  peritoneum  at  the  front  and  sides  of  the 
growth,  it  can  always  be  removed.  The  chief  trouble  is  expe- 
rienced in  deahng  with  the  bowel  afterwards.  There  are  three 
alternatives  : — 


272  MALIGNANT    DISEASE 

1.  To  close  or  pack  off  the  upper  end  of  the  rectum,  and  to 
bring  the  stump  of  the  sigmoid  out  of  the  abdomen  and  form  an 
artiiicial  anus. 

2.  To  remove  the  entire  rectum  and  bring  the  stump  of  the 
sigmoid  down  to  the  anus. 

3.  To  anastomose  the  ends  b}/  means  of  a  tube  tied  into  the 
sigmoid  and  passed  down  through  the  rectum  and  out  of  the 
anus. 

The  first  method  has  the  objection  that  it  leaves  the  patient 
with  a  permanent  artiiicial  anus  ;  while  the  second  involves  a 
most  formidable  operation  and  sacrifices  a  normal  rectum. 

The  third  method  gives  quite  satisfactory  results,  and  enables 
the  continuity  of  the  bowel  to  be  restored  in  cases  where  end-to- 
end  anastomosis  is  impossible.  It  will  be  described  in  detail 
later. 

Summary. 

1.  In  cases  where  acute  obstruction  is  present  at  the  time  of 
operation,  a  temporary  artificial  anus  should  always  be  made, 
and  excision  of  the  growth  postponed  till  a  later  time ;  or  the 
growth  should  be  excised  and  the  ends  of  the  bowel  brought  out. 

2.  Unless  the  bowel  above  the  growth  can  be  entirely  emptied 
before  operation,  an  artificial  anus  should  be  established  before 
proceeding  to  excise  the  growth  ;   or  Paul's  operation  be  done. 

3.  In  excising  the  growth,  the  bowel  should  always  be  resected, 
and  at  least  an  inch  of  normal  bowel  removed  on  each  side  of  the 
growth. 

4.  Whenever  possible  the  lymphatic  area  should  be  cleared 
with  the  growth  ;  but  inability  to  do  this  is  not  necessarily  a  bar 
to  successful  removal. 

5.  Immediate  end-to-end  anastomosis  after  excision  may  be 
performed  in  dealing  with  the  right  half  of  the  colon,  but  is 
dangerous  on  the  left  side. 

6.  Paul's  operation,  or  colotomy  followed  by  excision,  is  by 
far  the  safest  operation  when  excising  growths  of  the  sigmoid. 

7.  The  presence  of  enlarged  glands,  or  adhesions  to  other 
structures,  should  not  necessarily  be  taken  as  contra-indicating 
resection,  providing  removal  is  possible. 

Recurrence  of  the  Growth  after  Excision. — Owing  to 
the  fact  that  cancer  of  the  colon  tends  to  remain  localized  for 


OF    THE    COLON  273 

long  periods,  and  but  seldom  gives  rise  to  metastatic  deposits, 
recurrence  after  operation  is  not  very  common.  I  have  not 
collected  a  series  of  statistics  to  show  the  frequency  of  recurrence, 
because  owing  to  the  wideh-  different  operations  performed  by 
surgeons,  and  in  different  cases,  any  such  statistics  would  be 
valueless.  Until  a  more  or  less  uniform  operation  becomes 
recognized  in  excising  growths  of  the  colon,  such  statistics  can 
hardly  be  of  much  value.  I  have,  however,  been  able  to  find 
many  records  of  cases  in  which  the  patient,  after  resection  of  a 
growth  from  the  colon,  has  remained  free  from  recurrence  for 
long  periods. 

Mr.  S}Tnonds  has  recorded  a  case  in  w^hich  the  patient,  after  a 
growth  in  the  ileocaecal  angle  had  been  resected,  remained  free 
from  recurrence  ten  years  later.  Mr.  Paul  records  two  cases 
free  from  recurrence  six  and  five  years  respectively  after  excision. 
Mr.  Clogg  records  two  cases  six  and  four  years  after  operation 
and  free  from  recurrence.  Mr.  Movnihan  records  two  cases 
remaining  well  seven  years  after  operation  ;  and  nine  cases  well 
three  years  after.  Boselius  records  four  cases  free  from  recur- 
rence five  years  after  operation.  These  are  sufficient  to  show 
that  very  long  periods  of  freedom  from  recurrence  may  be 
obtained  after  resection  of  the    colon    for   cancer. 

Palliative  Operations. — Even  when  the  growth  cannot  be 
removed,  much  may  be  done  by  the  performance  of  a  suitable 
operation  to  render  the  patient  more  comfortable  and  prolong 
his  life.  The  operations  that  ma^^  be  performed  for  this  purpose 
are  : — 

1.  Excision  of  as  much  of  the  growth  as  can  be  got  away. 

2.  Short-circuiting  the  growth. 

3.  Making  an  artificial  anus  above  the  growth. 

Some  surgeons  have  advised  that,  even  when  it  is  found  at  the 
operation  that  there  are  glands  which  cannot  be  removed,  or 
metastatic  deposits  in  the  liver,  the  best  plan  is  still  to  excise 
the  primary  growth,  and  that  this  will  give  the  patient  a  longer 
lease  of  life  than  short-circuiting.  There  is  a  good  deal  to  be 
said  for  this  view,  and  always  the  possibility  that  the  glands 
which  are  not  removed  are  not  cancerous.  If  the  primary 
growth  can  be  easilv  removed  without  much  danger  to  the 
patient,  this  is  probably  the  best  treatment  ;  but  it  does  not 
seem  right  to  subject  the  patient  to  a  dangerous  and  prolonged 
operation  if  there  are  secondary  deposits  already  present  which 

lo 


274 


MALIGNANT    DISEASE 


cannot  be  removed.  Short-circuiting  the  growth  is  undoubtedly 
the  best  method  when  it  is  found  that  excision  is  impossible.  It 
does  away  with  the  danger  of  obstruction,  and  does  not  leave 
the  patient  with  the  discomforts  of  a  colotomy. 

If  the  growth  is  in  the  caecum,  the  ileum  should  be  divided, 
the  caecal  end  closed,  and  the  proximal  end  implanted  into 
the  ascending  or  transverse  colon.  This  gives  a  better  result, 
and  is  just  as  easily  performed  as  lateral  anastomosis  in  this 


Fig.  67.- — Diagram  showing  dififerent  methods  of  short-circuiting  a  tumour  of  the  colon. 
I. — Ileum  implanted  after  division  into  ascending  colon.  II. — Ditto,  but  caecum  excluded  and 
opening  by  fistula  on  skin  surface.  III. — Ileo-sigmoidostomy  after  dividing  ileum.  IV.— Ditto, 
and  exclusion  of  colon  with  fistula  to  skin.  V. — Transverfe  colon  anastomosed  to  sigmoid. 
VI. — Ileo-sigmoidostomy  for  growth  in  colon. 


situation.  Ileo-colostomy  by  lateral  implantation  seems  to  be 
the  best  operation  for  growths  in  the  right  half  of  the  colon,  and 
in  the  transverse  colon.  An  even  better  operation,  probably,  is 
to  divide  the  colon  above  the  anastomosis  and  bring  the  excluded 
portion  to  the  skin,  as  this  does  away  with  the  possibility  of 
feces  accumulating  in  the  excluded  portion  of  the  colon  ;  it  has, 
however,  the  disadvantage  of  leaving  the  patient  with  a  fistulous 


OF    THE     COLON  275 

opening.  When  the  growth  is  in  the  left  side  of  the  colon,  the 
choice  lies  between  lateral  anastomosis  between  the  transverse 
colon  and  sigmoid  and  ileo-sigmoidostomy.  In  a  few  cases  where 
the  growth  is  in  the  centre  of  the  sigmoid  loop,  lateral  anastomosis 
between  the  two  limbs  of  the  loop  will  be  suitable. 

Colotomy  is  the  only  available  method  when  the  growth  is 
situated  too  low  down  in  the  sigmoid  to  allow  of  the  ileum  being 
anastomosed  below  it.  It  is  also  not  safe  to  perform  short- 
circuiting  if  obstruction  is  present  at  the  time  of  operation,  and 
this  must  often  be  the  case.  Colotomy  must  then  be  done  ;  or, 
preferably,  a  faecal  fistula  established  above  the  growth,  and  a 
short-circuiting  operation  performed  after  the  obstruction  has 
been  relieved,  the  faecal  fistula  being  then  allowed  to  close. 

In  conclusion,  it  must  be  borne  in  mind,  when  a  tumour  of  the 
colon  is  discovered,  that  it  may  be  a  case  of  hyperplastic  tuber- 
culosis, and  not  cancer.  Short  of  cutting  open  the  tumour  it  is 
impossible  to  make  a  certain  diagnosis  between  these  two  condi- 
tions, and  in  view  of  this  possibiUty  the  tumour  should  either  be 
excised  or  short-circuited  if  it  can  be  managed  ;  for  if  the  case 
is  one  of  tubercle,  recovery  will  very  probably  follow  either  of 
these  operations  ;  whereas,  if  the  surgeon  closes  the  abdomen 
under  the  impression  that  he  is  dealing  with  a  hopeless  case  of 
cancer,  the  patient  will  almost  certainly  die. 


276 


Chapter    XIX. 

TRAUMATISM. 

The  colon  is  so  deeply  situated  in  the  abdominal  cavity,  and  so 
well  protected,  that,  apart  from  gross  injury  involving  the 
whole  or  greater  part  of  the  abdominal  viscera,  it  is  but  rarely 
the  seat  of  severe  traumatism. 

Rupture  of  the  colon  from  direct  violence  is  a  very  rare  con- 
dition, and  but  few  instances  have  been  recorded.  Out  of  292 
cases  of  abdominal  injuries  collected  by  Mr.  Makins  at  St. 
Thomas'  Hospital  in  nine  years,  the  intestine  was  injured  in  22, 
and  in  only  5  of  these  was  the  colon  involved. 

It  requires  a  very  serious  traumatism  to  rupture  the  colon, 
and  in  most  of  the  cases  the  cause  is  either  a  crush  such  as  will 
result  from  being  run  over  by  a  heavy  vehicle,  or  a  severe  blow 
such  as  the  kick  in  the  abdomen  by  a  horse. 

One  would  suppose  that  the  transverse  colon,  where  it  passes 
across  the  spinal  column,  would  be  the  part  most  likely  to  be 
thus  ruptured.  The  cases  I  have  been  able  to  collect  are  too  few 
to  warrant  any  conclusions  on  this  point,  but  at  least  it  may 
be  stated  that  the  transverse  colon  is  not  alone  affected,  for 
in  two  instances  the  ascending  colon  was  ruptured  as  the  result 
of  direct  traumatism  of  the  abdomen. 

The  nature  of  the  injury  of  the  colon  varies  considerably, 
from  a  complete  tear  or  tears  involving  the  whole  lumen  of  the 
bowel,  to  a  minute  opening.  In  some,  the  colon  was  apparently 
not  ruptured  at  the  time  of  the  accident,  but  was  so  damaged 
that  it  gave  way  in  one  or  more  places  later. 

In  a  case  recorded  by  Mr.  Battle,  the  rupture  occurred  at  the 
splenic  flexure  as  the  result  of  the  patient  being  run  over,  and 
the  tear  was  apparently  mainly  post-peritoneal. 

Rupture  of  the  colon  from  within  must  be  an  extremely  rare 


TRAUMATISM  277 

condition,  but  I  have  been  able  to  find  two  instances.  In  both 
the  nature  of  the  accident  was  similar.  In  one,  the  patient,  a 
man,  fell  off  a  step-ladder  on  to  an  umbrella  stand,  and  the 
handle  of  an  umbrella  entered  the  rectum  and  was  broken  off. 
It  found  its  way  into  the  transverse  colon  and  perforated  the 
bowel- wall.  The  umbrella  handle,  which  measured  7  inches  in 
length,  was  subsequently  removed  by  operation  from  the  trans- 
verse colon,  and  the  patient  made  a  good  recovery.  In  the  other 
case,  the  patient  feU  upon  a  broom  handle,  which  passed  up  the 
rectum  and  perforated  the  bowel  just  above  the  recto-sigmoidal 
junction.  The  patient  was  operated  on  a  few  hours  later,  when 
a  large  rent  was  found  in  the  anterior  wall  of  the  bowel.  It 
was  closed  with  stitches,  and  the  patient  recovered. 

Rupture  of  the  colon  from  indirect  violence  must  be  extremely 
rare,  but  McCaskey  has  recorded  a  case  in  which  the  splenic 
flexure  ruptured  as  the  result  of  violent  peristalsis  above  a 
stricture  of  the  sigmoid  flexure. 

As  a  rule,  in  a  rupture  of  the  colon  the  injury  is  compHcated 
by  severe  bruising  or  laceration  of  the  neighbouring  bowel,  or 
of  the  mesentery.  Surgical  emphysema,  owing  to  the  escape  of 
intestinal  gas  from  the  bowel  into  the  subperitoneal  areolar 
tissue,  has  been  present  in  some  of  the  cases. 

Treatment. 

If  the  severity  and  nature  of  the  injury  can  be  diagnosed, 
there  should  be  no  hesitation  in  resorting  to  immediate  operation. 
The  indications  for  operating  are  the  same  as  for  perforation 
of  the  bowel  in  any  part. 

It  will  be  but  seldom  that  the  exact  nature  and  site  of  the 
lesion  can  be  diagnosed.  As  a  rule,  all  that  can  be  known  is  that 
a  serious  injury  to  some  portion  of  the  bowel  has  occurred. 
Under  these  circumstances  a  median  incision  will  be  indicated, 
so  as  to  allow  the  whole  of  the  bowel  to  be  examined.  When 
the  rent  has  been  discovered,  it  will  depend  upon  the  nature 
of  the  lesion  as  to  what  procedure  is  adopted.  If  there  is  only 
a  small  rent,  and  the  neighbouring  bowel- wall  is  not  seriously 
damaged,  simple  closure  of  the  tear  by  Lembert  sutures  is  all 
that  is  necessary,  combined  with  careful  cleansing  of  the  peritoneal 
cavity,  drainage  being  provided  for  if  any  serious  soiUng  has 
occurred.  If  the  colon  is  completely  torn  across,  or  if  the  bowe]- 
wall  has  been  so  damaged  as  to  negative  any  hope  of  its  recovery, 


278  TRAUMATISM 

resection  of  the  damaged  portion  will  have  to  be  performed. 
The  bowel  may  either  be  united  end-to-end  by  suture,  or  the  ends 
can  be  closed  and  the  bowel  united  by  lateral  anastomosis.  In 
the  case  of  the  transverse  colon  or  sigmoid  flexure,  the  ends  of 
the  colon  can  be  brought  out  of  the  abdomen  after  resection  and 
sutured  to  the  skin  so  as  to  form  an  artificial  anus  ;  the  spur 
may  be  destroyed  later  on  and  the  opening  closed  b}^  plastic 
operation,  or  an  anastomosis  performed  at  some  later  period 
when  the  patient  has  recovered  from  the  shock  of  the 
injury. 

The  exact  character  of  the  operative  procedure  must,  how- 
ever, vary  in  different  cases  according  to  the  nature  of  the 
injury  and  the  condition  of  the  patient. 

Considering  the  serious  nature  of  the  injurjdn  these  cases,  and 
the  difficulty  of  making  a  correct  diagnosis  before  peritonitis 
has  developed,  the  results  of  operation  appear  most  encouraging. 
Thus,  out  of  six  cases  of  rupture  of  the  colon  submitted  to 
operation,  four  recovered  and  two  died,  while  of  the  cases  not 
operated  upon  both  died. 

The  following  curious  case  of  rupture  of  the  mesosigmoid  from 
direct  violence  seems  worth  recording  : — 

Case. — The  patient  was  a  man,  aged  20,  under  the  care  of 
Dr.  Ross  in  the  German  Hospital,  New  York.  He  was  struck  in 
the  abdomen  during  a  fight.  Shortly  afterwards  severe  pain  in 
the  abdomen  induced  him  to  come  into  the  hospital.  On  admis- 
sion a  mass  could  be  felt  in  the  right  iliac  fossa,  and  he  was 
much  collapsed.  The  abdominal  muscles  were  rigid.  Immediate 
operation  was  decided  upon.  An  intravenous  injection  was  given 
prior  to  operation,  as  the  patient  was  in  bad  condition.  On 
opening  the  peritoneum  much  free  blood  escaped.  There  was  no 
rupture  of  the  intestine,  but  an  extensive  haemorrhage  between  the 
layers  of  the  mesentery,  and  the  outer  layer  of  the  mesosigmoid 
was  denuded  of  its  serous  coat  for  about  4  inches.  There  was 
also  much  blood  behind  the  peritoneum.  The  serous  coat  of  the 
mesosigmoid  was  sutured  with  fine  silk.  Two  pieces  of  gauze  were 
packed  in  to  stop  the  oozing  from  the  mesenteric  wound.  A  faecal 
fistula  formed  on  the  eighth  day  from  the  pressure  of  the  gauze 
upon  a  portion  of  badly  nourished  bowel.  The  fistula  healed  spon- 
taneously on  the  sixteenth  day.  The  patient  left  the  hospital  well 
on  the  forty-fifth  day,  but  returned  six  days  later  with  pain  in  the 
abdomen  and  vomiting.  He  also  stated  that  his  bowels  had  not 
been  open  for  twenty-four  hours.     He  was  supposed  to  be  suffering 


TRAUMATISM  279 

from  chronic  obstruction,  and  it  was  thought  advisable  to  operate. 
At  the  second  operation  the  old  scar  was  excised.  The  sigmoid 
and  small  bowel  were  found  to  be  matted  together  in  numerous 
places.  The  adhesions  were  broken  up,  but  in  doing  so  the 
serous  coat  was  damaged  in  several  places,  and  in  one  place  an 
opening  was  made  in  the  bowel  which  had  to  be  sewn  up.  The 
patient  died  on  the  third  day  after  the  second  operation.  The 
cause  of  death  was  general  peritonitis. 


Chapter    XX 
COLOTOMY. 

The  object  of  this  operation  is  to  make  an  artificial  outlet  for  the 
faeces,  either  temporarily  or  permanently,  by  establishing  an 
opening  between  the  skin  surface  and  some  portion  of  the  colon. 

In  the  pre-Listerian  days,  when  surgeons  were  afraid  to  open 
the  peritoneal  cavity,  lumbar  colotomy  was  always  performed 
when  it  was  necessary  to  make  an  artificial  anus  ;  but  since  the 
introduction  of  antiseptic  methods  it  has  fallen  into  disuse,  and 
has  now  with  a  few  exceptions  been  entirely  replaced  by  inguinal 
trans-peritoneal  colotomy. 

This  is  an  operation  which  at  the  present  day  is  practically 
unattended  by  any  mortality.  The  following  is  the  only  instance 
I  have  met  with  in  which  a  fatal  result  was  caused  by  the 
operation  : — 

Case. — I  was  called  one  day  to  see  an  elderly  man  who  had 
symptoms  of  intestinal  obstruction.  He  was  suffering  from 
inoperable  cancer  of  the  rectum,  and  five  days  previously  a  left 
inguinal  colotomy  had  been  performed  by  another  surgeon.  The 
colotomy  had  been  done  by  the  stitch  method,  and  appeared  quite 
satisfactory  ;  but  although  the  bowel  had  been  opened  and 
aperients  given,  there  had  been  no  action  of  the  bowels,  and 
symptoms  of  acute  obstruction  had  developed.  A  csecostomy  was 
done,  but  the  patient  died  before  the  operation  could  be  com- 
pleted. Post  mortem  it  was  discovered,  on  opening  the  abdomen  in 
the  middle  line,  that  a  portion  of  the  great  omentum  had  been 
caught  up  in  the  colotomy  stitch  in  such  a  way  that  it  dragged  upon 
the  centre  of  the  transverse  colon,  and  had  formed  a  sharp  kink 
which  entirely  obstructed  the  bowel. 

We  must,  of  course,  not  confuse  the  mortality  due  to  diseased 
conditions  for  which  the  operation  is  performed  with  that  due 
to  the  operation  itself.  In  many  cases  it  is  performed  in  an 
attempt  to  save  the  life  of  a  patient  who  is  in  extremis,  and  in 
such  cases  it  not  infrequently  happens  that  the  patient  dies  in 


GOLOTOMY 


2«I 


spite  of  the  operation.     Colotom\'  should  in  skilled  hands  be 
almost  free  from  risk. 

The  usual  method  of  performing  colotomy  at  the  present  day 
is  to  make  a  small  vertical  incision  through  the  abdominal  wall 
about  half  way  between  the  umbilicus  and  the  left  anterior 
superior  spine  of  the  ilium.  Through  this  opening  a  loop  of 
sigmoid  is  pulled  out.  The  bowel  is  then  pulled  down  until 
that  portion  nearest  to  the  descending  colon  which  can  be  made 
to  reach  the  opening  is  found,  and  this  portion  is  used  to  form 


Fiq.  68. — Methcd  of  performing  inguinal  colotomy.  using  a  clip  to  form  the  spur. 

the  colotomy.  A  spur  is  now  made,  either  by  means  of  a 
mattress  stitch  passed  through  the  mesosigmoid,  or  preferabh* 
by  a  glass  rod  or  a  clip  which  is  passed  through  the  mesosigmoid 
and  allowed  to  rest  on  the  skin  on  each  side  of  the  wound.  A 
stitch  is  passed  through  the  skin  at  the  end  of  the  incision,  and 
through  the  anterior  longitudinal  muscle  band.  Such  a  stitch 
should  be  inserted  at  both  ends  of  the  wound,  to  anchor  the 
bowel  and  prevent  smy  further  prolapse.  Unless  a  large 
incision   has  been  made,   one    stitch  at    each    end    should    be 


282 


COLOTOMY 


sufficient.  If  there  are  an}/  large  appendices  epiploicae  thev 
should  be  ligatured  and  removed. 

In  many  text-books  the  position  for  the  incision  is  given  as 
the  junction  of  the  middle  and  outer  thirds  of  a  line  between 
the  umbilicus  and  the  left  anterior  superior  spine.  While  this 
incision  is  directl}^  over  the  colon,  it  has  the  disadvantage  that 
afterwards,  when  a  cup  has  to  be  fitted  over  the  colotomy 
opening,  the  edge  of  the  cup  tends  to  ride  up  on  the  iliac  crest 
as  the  patient  walks  or  moves,  and  this  results  in  leakage  and 
discomfort. 

I  prefer  to  make  the  incision  much  nearer  the  middle  of  the 
abdomen,  and  far  enough  away  from  the  pubes  and  iliac  crest  to 


Fig.  69. — Author's  incision  for  inguinal  colotomy. 


insure  that  any  apparatus  afterwards  fitted  will  rest  entirely 
on  the  abdominal  wall.  The  incision  is  made  through  the  outer 
fibres  of  the  rectus  muscle,  and  the  bowel  pulled  out  between  the 
muscle  fibres.  This  assists  considerably  in  giving  subsequent 
control. 

It  is  important  to  make  the  abdominal  wound  small,  as  the 
resulting  control  is  better.  An  incision  one-and-a-half  inches 
long  is  sufficient.  The  bowel  is  usually  opened  on  the  second 
day  after  operation.  For  this  purpose  no  anaesthetic  is  required, 
the  bowel  being  quite  insensitive.  A  small  transverse  cut 
should  be  made  with  a  pair  of  scissors  in  such  a  wa}-  as  to  partly 


GOLOTOMY  283 

divide  the  bowel.  A  transverse  incision  is  better  than  a  longi- 
tudinal one,  because  the  bleeding  is  less. 

If  it  is  necessary  to  open  the  bowel  at  once,  a  Paul's  tube 
should  be  tied  into  it  to  prevent  soiling  of  the  wound.  Some 
six  or  eight  days  later  the  bowel  is  completeh'  di\'ided  by  cutting 
it  across.  The  whole  bowel  should  be  completely  divided  by 
inserting  one  blade  of  the  scissors  along  the  track  of  the  glass  rod 
or  clip,  and  the  other  outside  the  bowel,  cutting  through  all  the 
intervening  tissue.  At  the  same  time,  any  bowel  projecting 
above  the  skin  level  should  be  trimmed  off  close  to  the  skin.  Xo 
anaesthetic  is  necessary.  One  of  the  chief  difficulties  in  securing 
control  over  the  opening  after  such  an  operation  is  the  lack  of 
an}^  sensation  which  can  warn  the  patient  that  the  bowel  is 
acting.  As  I  have  shown  in  discussing  the  physiology  of  the 
colon,  a  certain  amount  of  sensation  at  the  opening  usually 
develops  in  course  of  time.  In  such  cases  the  sensory  nerves 
doubtless  grow  into  the  mucous  membrane  from  the  skin,  and 
it  is  therefore  important  to  see  that  there  is  not  a  redundant 
fold  of  mucosa  outside  the  skin,  as  the  mucous  membrane  never 
becomes  sensitive  for  more  than  a  short  distance  from  the  skin 
edge  (see  diagrams,  page  16). 

Several  new  methods  of  performing  colotomy  have  been 
devised  with  the  object  of  giving  the  patient  better  control  over 
the  opening.  The  earliest  of  these  consisted  in  giving  a  twist 
to  the  bowel  above  the  opening,  or  in  stricturing  it  by  means  of 
a  ligature  ;  these,  however,  did  not  prove  satisfactory,  and  have 
been  abandoned.  Witzel  was  the  first  to  suggest  making  a 
valvular  opening  in  the  abdominal  wall.  This  was  done  as 
follows  :  A  loop  of  sigmoid  colon  was  first  brought  out  through 
the  usual  colotomy  incision,  and  another  smaller  incision  was 
made  below  the  pelvic  brim.  A  space  was  then  opened  up 
between  these  two  incisions  by  separating  the  internal  and 
external  oblique  muscles,  and  the  loop  of  bowel  was  dragged 
through  this  space  and  stitched  to  the  skin  at  the  lower  opening, 
the  upper  opening  being  completely  closed. 

Bailey's  modification  of  this  method  consists  in  opening  up  a 
space  between  the  skin  and  external  oblique  muscle,  and  bringing 
the  colon  out  through  an  incision  just  above  Poupart's  ligament. 

Tuttle  describes  a  modification  of  these  methods  as  follows  : 
The  ordinary  incision  is  made,  and  a  loop  of  colon  pulled  out. 
This  should  come  outside  for  at  least  two  inches.     The  lower 


284 


COLOTOMY 


fibres  of  the  external  oblique  are  then  pulled  downward,  and 
the  internal  obhque  is  spht  laterally  to  the  extent  of  about  |  of 
an  inch.  A  canal  is  next  made  between  the  skin  and  external 
obhque,  downward  for  2  inches,  and  made  to  open  through  the 
skin  just  above  Poupart's  hgament.  This  canal  should  be 
large  enough  to  admit  the  loop  of  colon  easily.  By  means  of  a 
tape  and  dressing-forceps  the  end  of  the  loop  of  bowel  is  drawn 
through  the  lateral  sHt  in  the  external  obhque,  and  downward 
through  the  canal  outside  this  muscle  until  it  emerges  at  the 
skin  opening.  It  is  held  here  by  stitches  or  a  glass  rod,  and  the 
abdominal  wound  is  closed  in  layers  (see  Fig.  70). 


It  is  claimed  for  these  methods  that,  by  wearing  a  truss  which 
presses  upon  the  skin  over  the  bowel  where  it  passes  sub- 
cutaneously,  the  patient  obtains  complete  control  over  both 
gas  and  faeces.  The  opening,  however,  is  placed  in  a  very  incon- 
venient position  in  the  fold  of  the  groin,  and  the  author's  ex- 
perience of  these  methods  has  been  that  the  control  is  httle  if 
any  better  than  that  obtained  bj^  bringing  the  bowel  straight 
through  the  abdominal  wall.  The  valvular  opening  is  good  at 
first,  but  in  a  ver\'  short  time  the  tension  of  the  bowel  straightens 
out  the  canal,  and  if  one  puts  one's  finger  into  the  opening  it  is 
found   to   pass   straight   through  the   abdominal  wall,  and   all 


GOLOTOMY 


285 


resemblance  to  a  valve  has  disappeared.  The  author  believes 
that  the  best  control  is  obtained  by  making  a  small  incision  and 
bringing  the  bowel  out  through  the  split 'fibres  of  the  rectus 
muscle.  When  the  patient  is  standing  or  walking  the  rectus 
will  be  contracted,  and  will  effectually  close  the  opening  and 
prevent  leakage.  Moreover,  at  any  time,  by  contracting  his 
recti,  he  can  to  a  considerable  extent  prevent  leakage  from  the 
opening.  I  have  found  that  patients  with  this  form  of  colotomy 
quickly  obtain  most  excellent  control,  and  are  able,  with  little 
or  no  trouble,  to  keep  themselves  clean. 


Fig.  71. — Diagram  to  show  the  incision  for  lumbar  colotomy.  The  incision  is  made  with  its 
centre  on  a  line  drawn  from  the  tip  of  the  last  rib  to  a  point  half-an-inch  behind  the  centre  of  the 
crest  of  the  ileum. 

Lumbar  ColotomY. — This,  formerly  the  favourite  operation, 
is  now  only  employed  in  special  cases  :  as,  for  instance,  when  the 
colon  cannot  for  some  reason  be  brought  up  to  the  abdominal 
wall,  and  inguinal  colotomy  is  therefore  impossible.  Right 
lumbar  colotomy  is  also  sometimes  performed  in  place  of 
caecostomy,  as  the  control  afterwards  is  better  owing  to  the  more 
solid  nature  of  the  faeces  in  the  ascending  colon. 

The  patient  is  laid  upon  his  side,  with  a  firm  cushion  or  sand- 
bag under  the  loin,  in  order  to  flex  the  trunk  sideways  and  open 
out  the  space  between  the  last  rib  and  the  ihac  crest.  The 
position  of  the  colon  is  indicated  by  a  vertical  fine  drawn  upwards 


286  COLOTOMY 

from  a  point  half-an-inch  behind  the  mid-point  between  the 
anterior  and  posterior  superior  spines  of  the  ilium. 

An  oblique  incision  is  made,  with  its  centre  over  this  line,  and 
midway  between  the  last  rib  and  the  crest  of  the  ilium.  The 
incision  should  be  about  3  inches  long.  The  anterior  edge  of 
the  quadratus  lumborum  should  be  exposed  in  the  back  of  the 
incision  and,  if  necessary,  parth'  divided.  The  wound  is  then 
opened  until  the  transversalis  fascia  is  met  with.  On  dividing 
this,  the  cellular  tissue  and  fat  are  seen,  and  when  these  are 
separated,  the  back  of  the  colon  will  be  exposed  in  the  bottom 
of  the  wound.  The  colon  is  pulled  up  into  the  wound  and  fixed 
to  the  skin  by  sutures  all  round,  an  oval  surface  of  colon  being 
left  exposed.  If  it  should  be  necessary  to  open  the  colon  at 
once,  a  Paul's  tube  or  one  of  the  author's  rubber  tubes  should 
be  tied  in,  otherwise  the  colon  is  opened  by  a  longitudinal 
incision  at  the  end  of  twent3--four  hours. 

If  the  colon  is  found  to  have  a  mesentery,  and  it  is  not  possible 
to  expose  it  extraperitoneally,  the  peritoneum  should  be  opened 
in  front  of  the  colon  and  the  bowel  brought  out  in  the  same  way 
as  in  performing  inguinal  colotomy.  The  colon  is  more  likely 
to  have  a  mesentery  on  the  right  than  on  the  left  side. 

Control  over  the  Opening  after  Colotomy. — Very  pessimistic 
opinions  are  generally  expressed  as  regards  the  comfort  of 
patients  upon  whom  colotomy  has  been  performed.  With  the 
object  of  ascertaining  whether  such  a  view  is  justified  I  investi- 
gated the  after-histories  of  several  of  the  patients  upon  whom 
I  had  performed  inguinal  colotomy  ;  I  found  that  in  old  people, 
especialh'  of  the  poorer  classes,  who  have  but  few  facihties  for 
keeping  themseh'es  clean,  there  is  usually  no  control  over  the 
discharge  from  the  opening.  This  is  more  particularly  the  case 
with  men,  and  with  patients  suffering  from  an  exhausting  illness, 
such  as  cancer  of  the  rectum. 

Where,  however,  the  patient  was  of  a  better  class,  and  was 
willing  and  able  to  take  a  little  trouble,  very  good  control  over 
the  opening  was  usually  obtained  ;  so  that  I  found  many 
patients  able  to  live  an  ordinary  Hfe,  mixing  wdth  other  people 
and  attending  to  their  business  without  difficulty  and  without 
others  knowing  of  their  disabilit\-. 

Some  patients  had  quite  a  surprising  amount  of  control. 
One  was  a  man  of  33,  with  a  left  inguinal  colotomj^  which  had 
been  made  o\'er  a  year  previously.     After  the  first  four  months 


GOLOTOMY  287 

he  was  always  able  to  tell  when  the  bowels  were  about  to  act, 
and  the  opening  did  not  cause  him  the  slightest  trouble  except 
on  one  occasion  after  he  had  eaten  something  which  disagreed 
with  him.  He  attended  to  his  business  and  played  football  for 
his  local  team. 

Another  patient  was  a  gentleman  who  lived  in  the  country 
and  hunted  several  times  a  week  ;  the  colotomy  had  been  done 
some  years  previously. 

One  patient,  a  stevedore  at  the  London  Docks,  who  had  a 
permanent  colotomy,  was  62  years  of  age,  and  returned  to  his 
employment  after  the  operation  and  worked  his  eight  hours  a 
day.  He  assured  me  that  the  colotomy  opening  did  not  interfere 
with  his  work,  and  he  was  quite  able  to  keep  himself  clean. 

The  best  control  was  obtained  where  there  was  a  small  opening 
without  prolapse  of  the  mucous  membrane,  and  when  the  patient 
wore  a  celluloid  cup  over  the  opening. 

The  use  of  a  plug  fitting  into  the  opening  prevents  any  sen- 
sation being  acquired  which  will  warn  the  patient  of  the 
necessity  of  attention. 

A  case  is  recorded  by  Dr.  Mitchell  of  a  woman  who  was  suc- 
cessfully delivered  of  a  child  ten  months  after  colotomy  had 
been  performed. 

Colotomy  by  Paul's  Method. — This  is  frequently  the  best 
and  safest  method  of  dealing  with  the  bowel  after  resection  of 
part  of  the  colon. 

The  colon  is  exposed  and  brought  out  of  the  wound  in  the 
same  way  as  in  performing  inguinal  colotom}-.  The  wound 
having  been  first  shut  off  by  gauze  packing,  the  colon  is  divided, 
and  a  Paul's  glass  tube  of  suitable  size  tied  into  either  end  by  a 
silk  ligature.  The  two  portions  of  colon  are  then  sewn  together 
side  by  side,  for  about  two  inches  of  their  length,  with  silk 
sutures,  with  the  object  of  ensuring  the  walls  being  in  contact 
later,  when  the  enterotome  is  used  (See  Fig.  72). 

The  tubes  come  away  in  about  a  week,  and  some  three  weeks 
later  the  spur  is  destroyed  by  means  of  an  enterotome  (see  page 
292).  After  the  spur  has  been  destroyed,  the  continuity  of  the 
bowel  is  re-established,  but  a  facal  fistula  still  remains,  which 
an  course  of  time  usually  closes  of  itself ;  but  it  may  be  many 
months  before  this  occurs,  and  it  is  better  as  a  rule  to  close  it  by 
operation.  If  the  spur  has  been  well  divided,  all  that  is  necessary 
is  to  dissect  the  mucous  membrane  off  the  skin  and  sew  it  up. 


288 


COLOTOMY 


There  is  no  necessity  to  open  the  peritoneal  cavity,  and  the  risk 
of  the  operation  is  therefore  shght. 

This  method  of  dealing  with  the  bowel  after  resection  of  the 
colon  for  stenosis  or  tumour  has  the  disadvantage  that  the 
patient  has  the  discomforts  of  a  faecal  fistula  for  some  time,  and 
that  a  second  operation  is  rendered  necessary.  On  the  other 
hand,  there  can  be  no  question  but  that  it  is  by  far  the  safest 
method.  It  is  practically  unattended  by  any  mortality,  while 
immediate  end-to-end  union  is  followed  by  a  high  death-rate. 

Cases  in  \A^hich  it  is  impossible  to  perform  Colotomy, — 
At  times  this  operation   has  to   be  abandoned,  either  because 


Fig.  72. — Paul's  method  of  performing  colotomy. 


the  colon  cannot  be  found,  or  because  it  cannot  be  made  to  reach 
the  skin.  Such  cases  are  of  considerable  interest,  as  they  cause 
great  difficulty  to  the  surgeon.  They  are  now  less  common  than 
in  the  days  when  lumbar  colotomy  was  the  usual  operation. 
Thus  a  case  is  recorded  by  Lockwood,  in  which  right  lumbar 
colotomy  could  not  be  performed  because  the  caecum  and  ascend- 
ing colon  lay  on  the  left  side  of  the  abdomen.  With  inguinal 
colotomy,  abnormalities  of  the  colon  are  less  likely  to  lead  to 
inability  to  perform  the  operation,  though  they  may  cause 
considerable  difficulty. 

The  sigmoid  flexure  being  situated  on  the  right  side  of  the 


COLOTOMY  289 

abdomen  instead  of  the  left  may  create  difBculty,  and  this 
condition  is  not  very  uncommon.  I  have  met  with  one  case  in 
which  the  operation  had  to  be  abandoned  owing  to  the  sigmoid 
being  fixed  in  the  right  ihac  fossa.  The  bowel  could  not  be 
found  on  the  left  side,  and  on  making  an  incision  on  the  right, 
it  was  found  to  be  impossible  to  bring  the  sigmoid  into  the  wound. 

In  two  cases  the  operation  was  impossible  from  the  fact  that 
the  entire  colon  was  fixed  and  immovable.  In  both  these  cases 
there  was  hyperplastic  tuberculosis  of  the  colon,  and  caecostomy 
had  to  be  done. 

Caecostomy. — This  operation  is  performed  when  it  is  not 
possible  to  perform  colotomy,  or  when  a  colotomy  opening  will 
not  be  above  the  seat  of  obstruction.  It  is  also  sometimes  done 
to  deflect  the  faecal  current  from  the  colon  in  cases  of  ulcerative 
colitis. 

The  csecum  is  exposed  through  an  oblique  incision,  the  centre 
of  which  lies  over  a  point  half  way  between  the  umbilicus  and 
the  right  anterior  superior  spine  of  the  ileum.  The  anterior 
wall  of  the  caecum  is  drawn  out  of  the  wound  and  sewn  to  the 
skin  and  aponeurosis  all  round  the  edges  of  the  wound.  The 
stitches  should  take  up  the  peritoneal  and  muscular  coats  only, 
and  when  they  are  all  inserted  the  peritoneal  cavity  should  be 
completely  shut  off,  and  an  oval  area  of  the  caecal  wall  about 
1^  in.  long  should  alone  remain  exposed.  Two  sutures  to  act 
as  guides  should  be  inserted  into  the  caecal  wall,  and  two  days 
later  the  caecum  is  opened  by  cutting  between  these  guide  sutures 
with  a  knife.  Another  method  of  performing  caecostomy,  and  a 
preferable  one  if  the  caecum  has  to  be  opened  at  once,  is  to 
enclose  a  small  circular  area  of  the  caecal  wall  about  ^  in.  in 
diameter  in  a  purse-string  suture.  This  portion  of  the  caecal 
wall  is  then  held  up  by  an  assistant,  and  a  small  incision  into 
the  cfficum  is  made  in  the  centre  of  the  circular  area  ;  through 
this  one  end  of  a  Paul's  tube  is  pushed,  and  the  purse-string 
suture  is  then  tied  firmly  on  to  the  tube.  The  caecal  wall  is 
stitched  into  the  wound  and  the  latter  closed,  leaving  the  Paul's 
tube  projecting. 

Owing  to  the  liquid  nature  of  the  contents  of  the  caecum,  the 
control  over  this  opening  is  very  unsatisfactory,  and  the  sur- 
rounding skin  often  becomes  sore  and  excoriated.  This  may  to 
some  extent  be  prevented  by  keeping  the  parts  well  greased  with 
lanolin. 

19 


290  CLOSURE    OF   AN 

CLOSURE     OF     A     F^CAL     FISTULA     OR     ARTIFICIAL 
ANUS     BY     OPERATION. 

A  Faecal  Fistula. — The  surgeon  may  be  called  upon  to  close 
a  faecal  fistula  which  has  resulted  from  disease  of  the  colon,  or 
which  he  or  some  other  surgeon  has  made,  but  which  is  no  longer 
necessar\-.  Operations  for  closing  faecal  fistulae  in  the  colon  are 
often  ver\-  difficult,  and  have  not  infrequently  been  attended  by 
a  fatal  result. 

Ver\-  careful  consideration  is  advisable  before  attempting  an 
■operation  of  this  nature  ;  it  is  not  justifiable  to  risk  the  patient's 
life  for  what  in  man\-  cases  is  onh-  an  inconvenience.  Providing 
the  normal  channel  to  the  anus  is  patent  and  not  seriouslv 
obstructed,  most  faecal  fistulae  will  close  spontaneously  if  given 
sufficient  time. 

The  most  difficult  fistulae  to  close  are  those  which  communicate 
with  the  csecum.  The  reasons  for  this  are  probabh'  the  fluid 
nature  of  the  contents  of  the  caecum,  and  more  especialh'  the 
pressure  to  which  any  join  in  the  caecal  wall  will  be  subjected 
owing  to  antiperistalsis  in  the  right  side  of  the  colon.  In  some 
cases  several  operations  have  had  to  be  performed  before  a 
faecal  fistula  in  the  caecum  could  be  made  to  close.  The  following 
table,  compiled  by  the  author,  shows  the  results  of  36  operations 
undertaken  for  this  piu"pose  or  the  closure  of  an  artificial  anus  : — 

Table  of  the  Results  of  Operatioxs  for  the 

Closure  of  F^cal  Fistul.^. 
Opening  closed  successfully     .  .  .  .  .  .      16 

First  operation  failed  to  close  the  opening  .  .        9 

Repeated  operations  failed      .  .  .  .  .  .        6 

Patient  died  as  a  result  of  the  operation  .  .        5 

36 

One  of  the  chief  difficulties  in  operating  to  close  a  faecal  fistula 
is  the  great  danger  of  the  wound  becoming  infected  during  the 
operation.  The  best  plan  is  to  disinfect  the  fistula,  either  with 
cautery  or  with  some  powerful  antiseptic,  and  then  to  dissect 
out  a  piece  of  skin  containing  the  fistula  and  the  entire  fistula 
itself  down  to  the  colon  ;  the  fistula  can  then  be  cut  off,  and  the 
stump  invaginated  into  the  bowel  %ATith  a  purse-string  suture 
(this  method  is  only  apphcable  to  ver^-  small  fistulae  or  those 
leading  into  the  caecum).  Another  method  is  to  excise  the 
portion  of  bowel  containing  the  fistula  and  carefully  close  the 


ARTIFICIAL    ANUS  291 

wound  in  the  bowel  with  a  double  row  of  sutures,  the  first  row 
taking  up  all  the  coats,  and  the  second  the  peritoneal  and 
muscular  coats  onl}-.  If  this  is  likely  to  cause  serious  narrowing 
of  the  bowel  lumen,  the  wound  in  the  bowel  should  be  sewn  up 
transversely  instead  of  longitudinally. 

Still  another  plan  is  to  resect  that  portion  of  the  colon 
containing  the  fistula  and  anastomose  the  ends.  This,  however,  is 
attended  with  much  more  risk  than  the  previous  methods.  The 
success  of  the  operation  in  any  case  depends  upon  very  careful 
asepsis  and  close  stitching. 

Where  the  fistula  is  associated  with  stenosis  of  the  colon,  there 
are  three  methods  which  have  been  used  for  getting  rid  of  it  : — 

1.  The  portion  of  bowel  with  which  the  fistula  communicates 
may  be  resected,  together  with  the  stenosis  or  tumour. 

2.  It  may  be  short-circuited. 

3.  It  may  be  excluded,  either  partially  or  totally. 

If  resection  is  decided  upon,  it  is  advisable  to  perform  a 
preliminary  short-circuiting  operation  ;  this  can  be  done  without 
interfering  with  the  fistula,  and  therefore  without  danger  of 
infecting  the  peritoneum. 

Short-circuiting  will  often  result  in  closure  of  the  faecal  fistula. 
Both  partial  and  total  exclusion  will  almost  certainly  fail  to  do 
this,  but  they  will  very  materially  diminish  the  discharge  there- 
from, and  greatly  increase  the  patient's  comfort. 

Artificial  Anus. — The  closure  of  a  colotomy  opening  will 
depend  very  largely  upon  the  manner  in  which  the  original 
operation  was  performed.  When  a  temporary  colotomy  opening 
has  been  made  by  the  method  described  on  page  281,  with  a 
.glass  rod  or  clip,  and  the  bowel  has  not  been  completely  divided, 
but  only  opened  on  its  anterior  aspect,  it  can  be  quite  easily 
closed  without  opening  the  peritoneal  cavity.  The  cut  edges  of 
the  wound  in  the  colon  are  first  dissected  free,  and  freshened  by 
cutting  away  the  extreme  edges.  They  are  then  brought  back 
into  position,  and  the  wound  in  the  colon  is  closed  by  suturing 
the  edges  carefully  together,  a  second  row  of  sutures  being 
inserted  over  the  first  to  make  all  tight.  The  colon,  being  now 
closed  again,  is  dissected  away  from  its  attachments  to  the 
abdominal  wall  until  the  peritoneum  is  reached.  This  is  not 
opened,  but  is  stripped  from  the  underside  of  the  abdominal 
waU  for  about  an  inch  all  round  the  opening,  or  sufficiently 
far  to  give  the  colon  a  free  lumen  without  kinking.     Lastly,   the 


292 


CLOSURE    OF   AN 


wound  in  the  abdominal  wall  is  closed  over  the  colon  (see 
Fig.  73).  The  portion  of  colon  which  originally  formed  the 
colotomy  is  thus  left  in  the  subperitoneal  tissue,  and,  if  leakage 
should  occur,  it  will  be  externally.  This  method  can  also  be 
used  when  the  gut  has  been  completely  divided.  The  ends 
of  the  colon  are  freshened,  then  anastomosed  by  suture,  and 
lastly  buried  in  the  subperitoneal  tissue. 


Fig.  73. — Method  of  closing  a  colotomy  opening  extra-peritoneally 


It  is  perhaps  unnecessary  to  point  out  that,  previous  to  any 
such  operation,  the  colon  should  be  well  cleared  by  aperients, 
and  steps  taken  afterwards  to  prevent  any  but  quite  liquid 
faeces  passing  through  it  for  the  next  ten  days. 

Another  plan  of  closing  a  colotomy  opening  without  exposing 
the  peritoneal  cavity  is  that  used  after  colotomy  by  Paul's 
method.  This  is  also  applicable  to  a  colotomy  opening  made 
in  the  ordinary  manner. 


Fi^.  74. — Enterotorae  for  destroying  the  spur. 


The  spur  between  the  two  portions  of  bowel  is  first  destroyed, 
so  as  to  make  the  upper  and  lower  Umbs  of  the  colon  communicate 
freely  below  the  skin  level.  This  is  done  by  means  of  an 
enterotome  ;  or  a  chp  forceps  with  long  blades  will  do  equalh' 
well. 

The  surgeon  places  his  first  and  second  lingers  into  the  two 


ARTIFICIAL    ANUS  293 

openings  of  the  colon,  and  assures  himself  that  there  is  nothing 
but  the  respective  walls  of  the  two  portions  of  colon  lying 
between  his  fingers.  The  two  blades  of  the  enterotome  are 
then  inserted  along  his  fingers  so  that  one  blade  hes  in  each  portion 
of  bowel,  and  the  instrument  is  closed  so  as  to  grip  tightly  the 
spur  over  a  distance  of  about  i-|  to  2  inches.  The  instrument 
having  been  firmly  fixed  in  position,  and  the  handles  supported 
by  dressings,  it  is  left  until  it  comes  loose  owing  to  the  destruction 
of  the  spur  by  sloughing.  The  blades  of  the  instrument  are 
very  apt  to  slip  up  the  spur,  and  it  may  be  necessary  to  re-apply 
it  several  times. 

If  any  of  the  mesentery  is  included  between  the  blades,  and 
sometimes  when  it  is  not,  there  is  a  considerable  amount  of  pain 
while  the  enterotome  is  cutting  its  way  through,  and  for  this  it 
will  be  necessary  to  give  morphia. 

It  takes  as  a  rule,  from  two  to  five  days  to  destroy  the  spur 
and  join  up  the  two  portions  of  bowel.  If  the  bowel  is  examined 
after  the  enterotome  has  become  loose,  it  will  be  found  (.hat 
there  is  some  swelling  of  the  edges  of  the  opening,  but  this  dis- 
appears in  a  few  days.  The  faeces  will  at  once  begin  to  pass  in 
part  by  the  normal  channel,  and  steps  can  then  be  taken  to 
close  the  skin  opening.  This  necessitates  an  anaesthetic.  The 
edges  of  the  mucous  membrane  should  be  dissected  loose  from 
the  skin  and  muscles,  turned  in,  and  stitched  together.  The 
skin,  and  as  much  of  the  deep  parts  as  possible,  should  then  be 
brought  together  above,  so  as  to  close  the  skin  opening. 

If  the  spur  is  freely  divided  with  the  enterotome,  the  external 
opening  will  close  itself  in  time  ;  but  this  may  take  many 
months.  This  is  a  very  safe,  though  rather  tedious,  method  of 
closing  a  colotomy  opening. 


294 


Chapter    XXI. 
APPENDICOSTOMY    AND    VALVULAR    CMCOSTOMY. 

APPENDICOSTOMY. 

This  operation  was  first  performed  by  Weir,  of  America,  in  a 
case  of  ulcerative  colitis. 

It  was  the  outcome  of  a  suggestion  by  Dr.  Hale  White  in 
1S95,  that  a  rightinguinal  colotomy  should  be  done  in  cases  of 
intractable  colitis. 

Weir's  original  operation  proved  extraordinarily  successful. 
The  patient  rapidly  recovered  as  the  result  of  daily  irrigation  of 
the  colon,  whereas  previously  the  only  satisfactory  results'  in 
similar  cases  had  been  obtained  by  establishing  an  artificial 
anus  on  the  right  side,  a  procedure  almost  as  objectionable  as 
the  disease.  Weir's  first  operation  was  performed  in  1902,  and 
since  then  it  has  been  done  in  a  considerable  number  of  cases, 
one  of  the  first  surgeons  to  draw  attention  to  the  operation  in 
England  being  the  late  Mr.  Keetley. 

It  forms  a  satisfactory  and  safe  method  of  enabling  the  whole 
colon  to  be  irrigated  with  any  desired  solution,  and  at  the  same 
time  does  not  leave  the  patient  with  an  offensive  and  leaking 
opening. 

As  originally  performed  by  Weir,  the  operation  consisted  of 
bringing  the  end  of  the  appendix  out  of  a  wound  in  the  abdomen 
and  stitching  it  to  the["skin.  The  caecum  was  not  drawn  up  to 
the'^abdominal  wall,  and  consequently  it  was  possible  for  a  loop 
of  intestine  to  become  strangulated  around  it  and  also,  if  inflam- 
mation of  the  appendix  should  occur,  the  peritoneal  cavity 
might  become  infected.  These  objections,  however,  were  soon 
realized  and  the  c^cum  pulled  up  so  that  the  entire  appendix 
lay  in  the  thickness  of  the  abdominal  wall. 

The  operation  is  performed  as  follows  :  An  oblique  incision  is 
made  over  McBurney's  point  in  the  same  way  as  in  the  ordinary 
operation  for  appendicectomy.  The  incision  need  only  be  a  short 
one,  and  an  inch  and  a  half  is  often  sufficient.     The  peritoneal 


APPENDICOSTOMY  295 

cavity  is  opened  and  the  appendix  found.  The  meso-appendix  is 
then  divided  close  to  the  appendix  for  from  -|  to  i  inch,  depending 
upon  the  length  of  the  appendix  ;  but  in  any  case  care  should  be 
taken  not  to  sever  the  artery  of  the  appendix.  If  it  is  cut, 
there  is  risk  of  the  appendix  sloughing  through  lack  of  adequate 
blood-supply.  The  artery  should  be  looked  for,  and  the  meso- 
appendix  only  divided  up  to  it,  and  no  farther.  The  appendix 
is  then  brought  out  of  the  wound  and  pulled  up  until  the  caecal 
Weill  comes  well  up  against  the  parietal  peritoneum.  One  or 
two  catgut  sutures  may  be  inserted,  so  as  to  anchor  the 
caecal  wall  to  the  fascia  and  parietal  peritoneum.  Two  or  three 
stitches  will  then  suffice  to  close  the  remainder  of  the  wound. 
Lastly,  a  single  stitch  should  be  passed  through  the  wall  of  the 
appendix,  so  that  it  can  be  anchored  to  the  skin  and  prevented 


^''S-  75- — I'iagram  to  show  the  method  of  fixing  the  caecum  and  appendi.x 
to  the  abdominal  wall. 

from  retracting.  The  dressings  are  then  applied  and  the  opera- 
tion is  finished.  In  appl3ang  the  dressings,  a  roU  of  gauze 
should  be  placed  on  each  side  of  the  appendix  to  prevent  the 
blood-suppl}'  being  damaged  by  the  pressure  of  the  bandage. 

If  there  is  any  doubt  about  the  patency  of  the  appendix,  it 
should  be  opened  at  once,  but  if  it  is  large  and  healthy  it  may  be 
left,  and  opened  two  or  three  days  later. 

In  performing  the  operation,  and  especially  in  closing  the 
wound,  the  importance  of  preserving  the  blood-supply  of  the 
appendix  should  be  borne  in  mind. 

About  two  or  three  days  later  the  dressings  should  be  removed, 
and  the  appendix  cut  off  about  J  to  J  an  inch  from  the  skin.  It 
is  better  not  to  cut  it  flush  with  the  skin.  An  appendicostomy 
catheter  (No.  7  or  No.  10)  can  then  be  passed  into  the  caecum 


2q6 


APPENDICOSTOMY 


through  the  stump  of  the  appendix,  and  irrigation  commenced. 
Later,  any  mucous  membrane  that  projects  above  the  skin  level 
can  be  cut  away  so  as  to  leave  a  neat  opening. 

The  above  seems  to  be  the  best  procedure  in  view  of  leaving 
as  good  an  opening  as  possible. 

If  the  appendix  is  cut  off  at  or  soon  after  the  operation,  a 
certain  amount  of  superficial  suppuration  in  the.  wound  will 
probably  occur,  and  this  often  leads  to  some  stricture  at  the 
orifice.  The  catheter  should  only  be  inserted  in  the  canal  for 
irrigation.  If  it  is  left  in  and  happens  to  be  rather  a  tight  iit, 
the  whole  appendix  may  slough,  owing  to  its  presence  interfering 
with  the  blood-supply,  which,  as  the  appendix  is  a  vestigial 
organ,  is  often  none  too  good. 

Tuttle  advises  that  at  the  end  of  thirty-six  hours  a  catheter 
should  be  passed  into  the  caecum,  and  a  ligature  tied  tightly 
round  the  appendix  on  to  the  catheter  and  left  in  position  till  it 
has  amputated  the  appendix.     As  has  already  been  mentioned; 


Full  Size  End 

Pig.  76. — Appendicostomy  catheter. 


however,  the  continued  presence  of  the  catheter  is  liable  to  cause 
sloughing  of  the  stump. 

The  operation  can  be  performed  in  a  very  short  time,  and 
with  the  minimum  of  exposure  of  the  abdominal  cavity.  It  is 
practically  free  from  any  serious  risk,  and  can  be  performed  on 
patients  whose  general  condition  is  bad  and  would  contra- 
indicate  any  more  serious  operation. 

For  these  reasons  it  is  admirably  suited  to  such  cases  as 
ulcerative  colitis  and  other  suitable  forms  of  colitis.  The  results 
obtained  from  irrigation  of  the  colon  through  an  appendicostomy 
wound  are  fully  considered  under  the  headings  of  the  diseases 
for  which  it  has  been  recommended. 

It  may  happen  that  at  the  operation  the  appendix  is  found  to 
be  diseased,  deformed,  or  rudimentary  :  in  such  cases  consider- 
able modification  of  the  technique  will  be  necessary  to  deal 
with  it,  or  it  may  not  be  possible  to  utilize  the  appendix  at  all. 
Under   such   circumstances   it   should   be   removed,    and   some 


APPENDICOSTOMY  297 

form  of  valvular  ctecostomy,  such  as  is  presently  described, 
performed. 

It  may  be  well  to  mention  here  that  care  should  be  taken  as 
to  the  fluid  used  for  irrigation.  Considerable  absorption  occurs 
in  the  colon,  and  it  is  dangerous  to  put  any  fluid  or  dose  of  a 
drug  into  the  colon  that  cannot  safely  be  put  into  the  stomach. 
This  has  not  sometimes  been  sufficiently  realized,  and  I  have 
seen  two  cases  of  boracic  acid  poisoning,  with  a  rash  and  vomit- 
ing, result  from  the  use  of  boracic  acid  lotion  for  irrigation,  and 
one  case  of  carbohc  acid  poisoning  from  the  use  of  weak  lysol 
solution. 

I  have  been  able  to  collect  50  cases  in  which  this  operation  has 
been  performed,  of  which  nine  are  my  own.  A  careful  anah'sis  of 
these  shows  that  while  the  operation  is  practically  devoid  of  any 
risk  as  regards  Hfe,  there  are  several  minor  compHcations  which 
may  result  and  cause  trouble,  though,  as  I  shall  be  able  to  show, 
these  may  be  avoided  by  care  in  performing  the  operation. 

Six  of  the  patients  died,  but  in  no  instance  was  death 
attributable  in  any  way  to  the  operation.  Two  died,  some 
months  later,  of  cancer  of  the  colon  present  at  the  time  of  opera- 
tion. One  died  of  peritonitis — the  operation  having  been  done 
to  relieve  distention  ;  one  died  of  miUary  tuberculosis  some 
weeks  later  ;  one  of  ulcerative  coHtis,  for  the  rehef  of  which 
the  operation  had  been  performed,  and  it  was  discovered  post 
mortem  that  the  ileum  was  also  ulcerated  ;  and  one  died  from 
another  operation  performed  some  time  later. 

Minor  complications  occurred  in  nine  cases.  In  one,  the 
opening  could  not  be  kept  open  more  than  four  weeks.  In  six 
cases  the  appendix  sloughed  :  in  four  of  these  it  was  due  to  a 
catheter  being  left  in  the  appendix  ;  in  the  other  two  it  was 
apparently  due  to  the  blood-supply  having  been  damaged  at  the 
operation.  In  two  of  the  cases  in  which  the  appendix  sloughed, 
the  opening  became  obliterated  ;  but  in  the  other  three  it  was 
kept  open  b}^  means  of  a  rubber  plug,  and  a  useful  opening 
resulted. 

In  two  cases  in  which  the  appendix  was  cut  off  at  the  operation , 
the  stump  retracted  inside  the  wound,  resulting  in  suppuration 
and  subsequent  difficulty  in  inserting  the  catheter.  In  another 
case  also,  suppuration  of  the  wound  occurred,  apparently  from 
the  same  cause.  In  three  cases  the  appendix  at  the  operation 
was  found  to  be  diseased  and  its  lumen  obliterated.     In  each 


298 


APPENDIGOSTOMY 


of  these  a  catheter  was  passed  into  the  caecum  through  a  small 
opening,  and  part  of  it  was  then  buried  in  the  caecal  wall  with 
Lembert  sutures,  the  other  end  being  brought  out  through  the 
abdominal  wall. 

In  one  of  my  cases  the  appendix  was  found  to  be  only  an  inch 
long  and  quite  rudimentary,  having  a  patent  lumen  for  only 
half  an  inch  from  the  caecum.  The  patient  was  a  stout  woman 
with  an  abdominal  wall  four  inches  thick.  The  caecum  was 
stitched  to  the  parietal  peritoneum,  and  the  end  of  the  appendix 
cut  off.  A  catheter  was  then  passed  through  the  short  stump 
into  the  caecum,  and  a  hgature  tied  tightly  round  the  stump  on 
to  the  catheter,  the  other  end  of  the  catheter  being  brought  out 
of  the  abdomen  (see  Fig.  77). 

This  case  did  very  well,  but  the  catheter  or  a  solid  rubber 


plug  has  to  be  left  in  the  canal  to  prevent  its  closing,  as  the  walls 
consist  only  of  fibrous  tissue.  In  another  case,  I  had  to  adopt 
the  same  procedure  because  the  appendix  had  no  lumen  for 
three-quarters  of  its  extent. 

In  only  one  case  was  there  any  leakage  of  faecal  material. 
The  patient  was  a  woman,  and  the  operation  had  been  i)erformed 
for  chronic  colitis.  -  There  was  considerable  leakage  from  the 
opening.  On  enquiry  I  found  that  the  surgeon  who  performed 
the  operation  divided  the  whole  of  the  meso-appendix,  and  in 
consequence  the  entire  appendix  sloughed  and  came  awa}^ 
The  result  was  therefore,  in  reality,  a  faecal  fistula  communica- 
ting with  the  caecum,  and  not  an  appendicostomy  opening. 

The  results  of  appendicostomy  as  regards  the  operation  itself 
are  most  satisfactory.     After  the  wound  has  healed  the  opening 


APPENDICOSTOMY  299 

is  barely  noticeable,  appearing  merely  as  a  small  pink  spot  on 
the  abdominal  wall  (see  Fig.  78).  No  leakage  at  all  occurs 
through  the  opening  when  the  catheter  is  withdrawn,  or  at  least 
lias  not  in  any  of  the  cases  I  have  seen.  In  one,  I  injected 
sufficient  water  into  the  colon  to  cause  marked  distention  of  the 
abdomen,  and  on  removing  the  catheter  there  was  no  leakage 
from  the  opening.  Neither  flatus  nor  fseces  escape,  and  the 
presence  of  the  opening  causes  the  patient  no  inconvenience 
whatever.  Most  patients  find  it  quite  unnecessary  to  wear 
anvthing  over  it. 


/'/["".  78. — Photograph  .showing  the  appearance  of  an  appendicostomj'  opening  three  j"ears  after 
operation.     The  opening  is  still  patent.     {Au!/ii>?-s  case.) 

Should  it  be  necessary  to  close  the  opening,  all  that  is  re- 
quired is  a  touch  with  the  cautery  or  the  application  of  a  Httle 
nitric  acid  to  the  mucous  Uning  of  the  opening,  the  wound 
readily  healing  in  a  few  days. 

It  is  better  to  keep  it  open  till  all  possibility  of  its  being 
required  is  gone,  and  as  it  causes  no  inconvenience,  this  can 
readilv  be  done. 


300 


C^COSTOMY    FOR    IRRIGATION 


Irrigation  through  the  opening  can  be  carried  out  easily  by 
the  patient,  and  he  is  not  prevented  from  hving  his  usual  Ufe  or 
from  going  into  the  society  of  others  in  any  way.  Several 
patients  assured  me  that  the  opening  caused  no  inconvenience, 
and  one  (a  labouring  man)  said  that  he  found  it  saved  him  time, 
as  he  was  always  certain  of  being  able  to  empty  his  bowel  in 
three  or  four  minutes. 

All  that  is  necessary  to  irrigate  the  bowel  is  to  pass  a  catheter 
into  the  opening  and  attach  a  Higginson's  sjn-inge  to  the  other 


Fig.  79. — Diagram  to  show  method  of  making  a  valvular  caecostomy  in  cases 
where  the  appendix  cannot  be  utilized. 


end.  The  fluid  is  then  pumped  into  the  caecum  in  a  few  minutes, 
and  allowed  to  run  out  at  the  anus.  If  oil  is  used  it  is  best  put 
in  with  a  glass  syringe,  as  it  flows  too  slowly  through  a  funnel. 

CAECOSTOMY     FOR     IRRIGATION     OF     THE     COLON. 

In  cases  where  the  appendix  cannot  be  used,  this  operation, 
or  some  modification  of  it,  can  be  performed. 

A  small  opening  is  made  in  the  wall  of  the  csecum  just  large 


OF    THE    COLON  301 

enough  to  admit  the  end  of  a  No.  10  catheter  (of  soft  rubber). 
The  end  of  the  catheter  is  passed  through  this  hole  for  about 
f  inch.  A  series  of  Lembert  sutures  are  then  commenced,  well 
beyond  the  hole,  and  continued  over  the  catheter  for  about 
I J  inches.  These  should  be  so  placed  that,  when  they  are  tied 
up,  the  catheter  for  about  an  inch  will  be  buried  in  the  wall 
of  the  caecum.  The  caecal  wall  where  the  catheter  passes 
through  is  then  anchored  firmly  to  the  bottom  of  the  wound, 
the  base  of  the  catheter  is  brought  out  of  the  wound,  and  the 
remainder  closed. 

This  makes  a  very  good  opening  and  does  not  leak,  but  it  is 
necessary  for  a  small  rubber  plug  to  be  worn  to  prevent  the 
opening  from  cicatrizing  up. 


302 


Chapter  XXII. 
RESECTION    AND    ANASTOMOSIS    OF    THE    COLON. 

THE     PREPARATION      OF     THE     PATIENT     FOR     AN 
OPERATION      UPON     THE     COLON. 

One  of  the  most  important  factors  in  obtaining  successful 
results  from  operations  upon  the  colon  is  the  preparation  of  the 
patient.  When  we  have  to  operate  for  acute  obstruction,  or 
other  urgent  symptoms  due  to  disease  in  the  colon,  it  is  often 
impossible  to  have  the  patient  properly  prepared.  Under  such 
circumstances  immediate  operation  is  of  more  importance 
than  any  other  factor,  and  the  advantages  which  will  result  from 
careful  preparation  have  to  be  sacrificed.  For  this  reason,  most 
operations  performed  for  urgent  obstructive  symptoms  are  of 
a  simple  nature,  usually  some  form  of  colotom}^  In  most  cases  in 
which  an  anastomosis  or  resection  has  to  be  performed  there 
is  no  great  urgency,  and  careful  preparation  of  the  patient  is 
possible. 

This  is  of  almost  as  much  importance  as  the  skill  of  the 
operator  ;  and  the  best  results  are  undoubtedl}'  obtained  by 
surgeons  who  pay  most  attention  to  this  part  of  the  treatment. 
It  is  not  sufficient  for  the  preparation  to  be  left  to  the  nurse,  with 
a  few  brief  directions  ;  the  surgeon  should  himself  see  that  the 
preparatory  treatment  is  carefully  and  efficiently  carried  out. 
A  week,  or  even  longer,  is  not  too  much  to  devote  to  getting  the 
patient  ready  for  operation  if  an  anastomosis  is  to  be  performed. 
There  are  two  objects  to  be  aimed  at  :  first,  that  the  colon 
shall  at  the  time  of  operation  be  as  nearl}^  as  possible  empty  ; 
and  second,  that  its  contents  shall  be  rendered  as  far  as  possible 
aseptic.  It  is,  of  course,  not  possible  to  render  the  interior  of 
the  colon  aseptic,  but  much  may  be  done  to  rid  it  of  pathogenic 
bacteria,  and  to  lower  the  virulence  of  those  that  remain. 

The  bowel  should  first  of  all  be  well  cleared  by  means  of  a 
purge,  and  for  this  purpose  nothing  is  better  than  a  dose  of 
castor  oil  (from  a  half  to  one  ounce) .     This  may  with  advantage 


PREPARATION     OF    PATIENT  303 

be  given  a  week  before  the  operation.  After  this,  the  bowels 
should  be  kept  acting  daily  by  some  mild  aperient,  such  as  a 
small  dose  of  magnesia  or  cascara.  The  patient  should  not  be 
restricted  as  regards  his  diet,  but  be  instructed  to  eat  onh'  plain 
cooked  food,  and  to  avoid  vegetables,  fruit,  or  other  substances 
which  will  leave  an  indigestible  residue.  The  teeth  should  be 
examined,  and  if  carious  or  otherwise  unhealthy,  the  patient 
should  go  to  a  dentist  and  have  them  put  right  or  extracted.  An 
antiseptic  mouth-wash  should  in  any  case  be  ordered  twice  daily 
to  ensure  that  the  mouth  is  as  clean  as  possible. 

There  are  several  ways  in  which  we  can  advantageously 
modifv  the  number  and  variet\'  of  the  bacteria  in  the  colon.  We 
can  give  intestinal  antiseptics  by  the  mouth,  such  as  hquor 
hydrarg.  perchlor.  3],  salol  gr.  x,  or  beta-naphthol  gr.  x,  three 
times  daily.  A  more  recent  and  more  efficient  method  of  purify- 
ing the  colon  is  b}-  the  use  of  the  lactic  acid  ferment.  This  acts 
by  introducing  into  the  intestine  a  harmless  micro-organism 
which  will  destroy  and  take  the  place  of  those  which  are  already 
present.  The  best  preparation  for  the  purpose  is  a  fresh  culture 
of  the  Bulgarian  bacillus  prepared  in  a  scientific  laboratory. 
Two  tablets  of  the  dried  culture  should  be  given  three  times 
a  day  in  a  little  sweetened  milk.  If  a  fresh  laboratory  culture 
is  unobtainable,  a  good  brand  of  soured  milk  should  be  given, 
the  dose  being  about  two  pints  a  day.  In  either  case  it  should 
be  given  before  meals,  and  at  the  end  of  a  day  or  two  the  stools 
should  be  examined  for  the  bacillus.  As  soon  as  the  bacillus  has 
appeared  in  the  stools,  the  dose  by  the  mouth  may  be  cut  down 
by  a  third.  This  treatment  must  be  commenced  some  time 
before  the  operation,  in  order  to  give  the  bacillus  time  to  become 
■acclimatized  to  the  intestine.  Occasionally  some  degree  of 
digestive  disturbance  follows  the  use  of  the  lactic  acid  bacillus, 
and  in  that  case  the  operation  should  not  be  performed  until  it 
has  passed  off.  The  effect  of  this  treatment  will  be  to  render  the 
■colon  as  nearly  aseptic  as  it  is  possible  to  make  it.. 

On  the  da}-  before  the  operation  the  patient  should  be  given 
a  smart  purge,  and  the  diet  be  reduced  to  a  light  and  easily 
digestible  form.  On  the  evening  before  the  operation  a  soap- 
and- water  enema  (two  pints)  should  be  given.  I  always  order 
15  gr.  of  pulv.  ipecac,  comp.  or  i  oz.  of  mist,  catechu 
comp.  to  be  given  at  the  same  time  as  the  enema.  Next  day, 
four  hours  before  the  operation,  an  enema  of  plain  warm  water 


304 


PREPARATION    OF    PATIENT 


(two  pints)  should  be  given.  The  object  of  the  opium  is  to 
arrest  peristalsis  and  to  prevent  the  last  enema  from  inducing 
peristaltic  contractions,  as  it  otherwise  will  do,  and  so  bringing 
down  more  material  into  the  colon.  It  also  has  the  advantage 
of  helping  the  patient  to  sleep  the  night  before  the  operation, 
which  he  will  often  be  unable  to  do  without  aid.  Whatever 
opinions  surgeons  may  hold  with  regard  to  the  use  of  opium 
after  abdominal  operations,  there  can  be  no  objection  to  its 
employment  beforehand. 


I^ig.  80. 


The  patient's  abdomen  will,  of  course,  be  shaved,  and  a 
compress  applied  on  the  day  previous  to  operation.  No  food 
should  be  given  on  the  morning  of  the  operation,  though  a  cup 
of  weak  tea  or  some  other  form  of  fluid  may  be  allowed  two  or 
three  hours  before  the  time.  An  exception  to  this,  however,  is 
often  advisable  in  the  case  of  elderly  and  very  young  patients. 
In  addition  to  the  above  preparatory  treatment,  I  usually  give 


PREPARATION     OF    PATIENT  305 

the  patient  two  or  three  teaspoonfuls  of  white  vasehne  by  the 
mouth  for  two  days  before  the  operation,  and  continue  it  after- 
wards. This  makes  certain  that  the  fseces  will  not  become 
consolidated,  and  that  there  can  only  be  liquid  f feces  to  pass  the 
line  of  anastomosis.  Petroleum  may  either  be  given  as  white 
vaseline,  to  which  some  flavouring  has  been  added,  such  as 
peppermint,  or  as  the  liquid  petroleum  of  the  Pharmacopoeia. 

If  it  is  anticipated  that  the  operation  will  cause  shock,  I  like 
to  give  a  hypodermic  injection  of  morphia,  gr.  |-,  just  before 
commencing  the  ansesthetic.  This  also  reduces  the  amount  of 
anaesthetic  required,  and  renders  subsequent  vomiting  less  likely 
to  occur.  The  patient  should  be  well  protected  against  cold 
and  exposure  during  the  operation,  either  by  a  jacket  and 
trousers  of  gamgee  tissue,  or  by  some  form  of  woollen  clothing 
which  will  not  require  to  be  removed. 

Mr.  Arbuthnot  Lane's  plan  for  preventing  shock  in  these 
operations  by  the  subcutaneous  infusion  of  warm  saline  during 
and  after  the  operation  is  excellent.  Fig.  80  shows  a  very  useful 
apparatus,  by  means  of  which  the  saline  can  be  kept  at  the 
desired  temperature  for  long  periods  without  constant  attention. 
All  that  is  necessary  is  to  connect  the  apparatus  to  a  large  hypo- 
dermic needle  put  under  the  skin  of  the  axilla,  and  to  keep  the 
tank  filled  with  sterihzed  salt  solution.  The  tank  should  only 
be  raised  about  a  foot  above  the  needle,  so  that  infusion  occurs, 
slowly.  The  heat  is  maintained  at  the  required  temperature 
by  electricity  from  the  ordinary  house  supply. 

RESECTION     OF     THE     COLON. 

The  colon  may  be  resected  in  part  or  in  whole.  The  best 
and  easiest  method  of  dealing  with  a  seriously  diseased  colon  is 
to  resect  a  length  containing  the  diseased  area.  If  the  entire 
colon  is  so  seriously  diseased  that  it  is  not  capable  of  recovery. 
it  can  be  completely  resected. 

Whenever  possible,  that  portion  which  it  is  proposed  to  resect 
should  be  drawn  out  of  the  abdomen,  and  the  abdominal  wound 
and  peritoneum  carefully  protected  by  gauze  packing.  The 
loop  of  bowel  is  then,  as  far  as  possible,  emptied  by  milking  out 
the  contents,  and  an  intestinal  clamp  is  placed  on  the  bowel-wall 
above  and  below  the  points  at  which  it  is  proposed  to  divide  the 
gut.  The  division  should  always  be  made  through  healthy 
bowel-wall,  and  well  clear  of  the  lesion.     In  the  case  of  cancer, 

20 


3o6 


RESECTION    OF    THE    COLON 


the  bowel  should  be  divided  at  least  one  clear  inch  from  the 
edges  of  the  growth.  In  order  to  be  certain  of  preserving  a  good 
blood-supply  to  the  edges  of  the  bowel,  the  bowel-wall  should  be 
divided  slighth^  obhquely,  the  greatest  amount  of  bowel  being 
removed  on  the  side  opposite  the  mesocolon  (see  Fig.  8i). 
When  the  bowel  has  been  divided,  and  the  diseased  area  removed, 
the  ends  of  the  divided  gut  should  be  cleaned  with  gauze  to 
remove  an}^  faecal  material.  The  mucous  membrane  always 
prolapses  to  some  extent  beyond  the  other  coats,  and  if  anasto- 
mosis is  to  be  performed,  this  projecting  ring  of  mucosa  should 
be  carefull}^  trimmed  off  with  scissors,  so  that  all  the  coats  are 
left  level.  This  materially  aids  accurate  apposition  of  the  ends 
when  performing  anastomosis. 


Fig.  8i. — Diagram  to  show  the  way  in  whicli  the  arteries  pass  from  the 
arterial  arcades  to  the  cohiii  wall. 


Method  of  Dealing  with  the  Mesocolon. — If  resection  has 
been  performed  for  malignant  disease,  a  wedge-shaped  portion 
of  the  mesocolon  should  always  be  removed  in  one  piece  with  the 
resected  bowel.  And  it  is  advisable  to  remove  as  far  as  possible 
all  the  lymphatic  area  immediately  draining  the  growth.  The 
indications  for  removing  this  area  have  been  alread}^  discussed 
fully  in  Chapter  XVIII. 

When  it  is  not  necessary  to  remove  any  of  the  mesocolon,  the 
loose  fold  left  after  resection  can  be  turned  back  on  itself  and 
sutured  together.  All  that  is  necessary  is  to  ensure  that  no 
opening  or  pocket  is  left  which  might  result  in  the  forn'iation  of 
an  internal  hernia  at  a  later  period. 

There  are  various  methods  of  dealing  with  the  bowel  after 
resection,   and  these,   and  the  indications  for  each,   have  been 


ANASTOMOSIS  307 

already  discussed.     It  remains  to  describe  the  various  methods 
of  anastomosis. 

ANASTOMOSIS. 

I  shall  only  describe  anastomosis  by  direct  suture,  for  although 
there  are  a  great  variety  of  methods  depending  upon  the  use  of 
some  special  apparatus,  such  as  a  bobbin  or  button,  these  have 
now  been  almost  entirely  discarded  in  favour  of  direct  suture. 
This  is  both  better  and  safer  than  the  use  of  bobbins,  and  can 
be  performed  as  quickly  after  a  little  practice.  Many  successful 
anastomoses  have  been  performed  in  the  colon  with  a  Murphy's 
button  ;  but  on  the  other  hand  there  have  been  many  fatalities 
which  were  directly  attributable  to  its  use. 

End-to-end  Anastomosis. — This  is  as  a  rule  only  possible  in  the 
transverse  and  pelvic  portions  of  the  colon.  The  results  of  end- 
to-end  anastomosis  are  not  nearly  so  satisfactory  as  in  the  case 
of  the  small  intestine.  In  the  latter  the  operation  has  quite  a 
low^death-rate  ;  but  in  the  colon  the  mortality  is  nearly  30  per 
cent. 

Out  of  89  cases  of  which  I  have  been  able  to  find  records, 
6o;[recovered  and  29  died.  Moreover,  of  those  patients  who 
recovered,  a  number  developed  a  feecal  fistula  as  the  result  of 
the  operation. 

End-to-end  Anastomosis  by  Suture. — The  colon  having  been 
clamped  and  the  diseased  portion  resected,  the  two  ends  of 
the  colon  enclosed  in  the  clamps  are  brought  together,  so  that 
they  lie  parallel  with  one  another.  The  mucous  membrane 
which  generally  projects  from  each  end  of  the  bowel  is  then  cut 
off  with  scissors,  so  that  the  mucous  membrane  is  flush  with  the 
other  bowel  coats  ;  this  is  advisable,  as  it  enables  a  much  better 
union  to  be  made.  A  single  mattress  suture  is  next  put  in, 
taking  up  all  the  coats  and  joining  the  two  mesenteric  borders 
of  the  colon.  This  suture  should  bring  the  two  mesenteric 
borders  into  accurate  apposition,  and  the  knot  should  be  tied 
on  the  mucous  side  ;  the  ends  should  be  left  long  to  act  as  a 
guide  while  the  remaining  sutures  are  being  passed. 

A  continuous  through-and-through  suture,  taking  up  all  the 
coats,  should  next  be  inserted,  starting  from  the  mesenteric 
border  and  continued  halfway  round  the  bowel.  It  should  then 
be  tied  off,  and  a  similar  suture  started  also  from  the  mesenteric 
"border  and  carried  along  the  opposite  side.     After  the  first  turn 

20A 


3o8  ANASTOMOSIS 

of  this  suture  has  been  inserted,  the  guide  suture  in  the  mesenteric 
border  should  be  cut  off.  The  two  continuous  sutures  are  tied 
together  where  they  meet  opposite  the  mesenteric  attachment. 

Over  this  first  suture  Hue  a  second  suture  of  fine  silk  should 
now  be  inserted  uniting  the  peritoneal  coats  only.  This  peri- 
toneal suture  should  preferably  be  inserted  in  two  portions,  each 
going  halfway  round  the  bowel ;  this  minimizes  the  risk  of 
puckering  the  bowel. 

Some  surgeons  prefer  to  use  silk  for  the  first  suture  which 
passes  through   the  mucous  membrane,  but   stout  chromicized 


catgut  is  perhaps  better,  for  this  suture  must  come  out,  as  it 
becomes  infected  from  the  mucous  membrane,  and  if  made  of  silk, 
a  certain  amount  of  sloughing  will  accompany  its  discharge  into 
the  bowel.  In  one  instance  I  examined  with  the  sigmoidoscope 
the  line  of  union  two  months  after  end-to-end  anastomosis  had 
been  performed  in  the  sigmoid  flexure,  and  was  able  to  see 
the  small  ulcers  in  the  mucous  membrane  all  round  the  bowel 
where  the  silk  stitch  had  been,  and  which  were  still  unhealed. 

After  the  ends  of  the  bowel  have  been  joined,  the  mesosigmoid 
or  mesentery  should  be  repaired  so  as  not  to  leave  a  hole  through 


Fig.  83. 

which  small  bowel  may  become  strangulated.  This  is  easily 
managed  with  a  continuous  catgut  or  silk  suture. 

In  the  case  of  resection  of  the  csecal  end  of  the  colon,  if  the 
ileum  and  colon  are  to  be  united  end  to  end,  it  is  necessary 
first  of  all  to  make  the  two  ends  of  bowel  the  same  size.  There 
are  several  methods  of  doing  this. 

The  ileum  may  be  cut  obliquely  and  the  colon  transversely. 
(See  Fig.  82). 

The  ileum  may  be  joined  to  the  colon  and  then  the  excess  of 
colon  sewn  up.     (See  Fig.  83). 


ANASTOMOSIS  309 

A  V-shaped  piece  of  the  colon  may  be  cut  out  on  the  side 
opposite  the  mesenteric  attachment,  and  the  V-shaped  wound 
sewn  up  to  make  the  end  of  the  colon  the  same  size  as  the  ileum. 
This  is  Madelung's  method.     (See  Fig.  84.) 

Doyen  has  invented  an  ingenious  method  by  which  a  sort  of 
artificial  ileocaecal  valve  is  formed.  The  end  of  the  ileum  is 
turned  inside  out  so  as  to  form  a  cuff.     The  end  of  the  colon  is 


next  reduced  till  it  is  the  same  size  as  the  ileum,  the  ileum  is 
inserted  into  it,  and  the  edge  of  the  turned-back  cuff  sewn  to  the 
edge  of  the  colon.     (See  Fig.  85.) 

Lateral  Anastomosis. — Lateral,  instead  of  end-to-end  anasto- 
mosis, may  be  performed  after  resection  of  the  colon  or  in 
performing  a  short-circuiting  operation.  When  the  ileum  and 
colon  have  to  be  joined  it  is  an  easier  operation  than  end-to-end 


r 


^ 


Fish's- 

anastomosis.  If  performed  after  resection,  the  two  ends  of  the 
bowel  are  first  closed.  This  may  be  done  by  sewing  up  the  end 
and  invaginating  it,  a  purse-string  suture  or  a  series  of  Lembert 
sutures  being  afterwards  inserted  to  further  protect  the  end. 
Mr.  Lane's  method  is  to  put  a  ligature  round  the  ends  of  the 
divided  bowel  and  then  invaginate  the  ligatured  end  with  a 
purse-string  suture. 


310 


ANASTOMOSIS 


The  two  portions  of  bowel  which  are  to  be  united  are  then 
placed  side  by  side — care  being  taken  to  see  that  peristalsis  will 
occur  in  the  right  direction — and  joined  together  side  to  side  for 
about  2  to  2|  inches  with  a  peritoneal  stitch  taking  up  the  peri- 
toneal and  muscular  coats  only-  This  suture  is  not  cut,  but  left 
long. 

An  incision  in  the  long  axis  of  the  bowel  is  now  made  into 
both  portions  of  bowel,  about  2  inches  long  and  close  to  the 
line  of  suture.  Any  projecting  mucous  membrane  is  cut  away, 
and  a  continuous  catgut  suture  is  inserted,  taking  up  all  the 
bowel  coats.  This  is  continued  right  round  the  openings  until 
they  are  joined  together.  Lastly,  the  peritoneal  stitch  is  con- 
tinued until  it  reaches  the  place  where  it  started,  thus  forming 
a  double  Hne  of  suture  and  covering  in  the  first  Une. 


Fig.  86. — Diagram  to  show  the  method  of  inserting  guide  sutures  in  performing 
anastomosis  by  implantation. 


When  possible  it  is  better  to  perform  the  anastomosis  before 
the  resection,  and  also  to  close  the  ends  of  the  portion  of  colon 
which  it  is  proposed  to  resect.  There  is  thus  considerably  less 
danger  of  soiUng  the  peritoneum. 

In  any  case,  after  performing  the  anastomosis,  the  edges  of 
the  divided  mesocolon  must  be  carefully  stitched  together  to 
avoid  leaving  any  gap  or  hole  through  which  the  small  bowel 
can  pass  and  become  strangulated. 

Lateral  Implantation. — This  is  in  some  ways  preferable  to 
lateral  anastomosis,  and  is  favoured  by  many  surgeons.  It  is 
much  better  than  end-to-end  anastomosis  when  dealing  with  the 
ileum  and  colon,  as  it  removes  the  difficulty  of  the  different  sizes 
of  the  two  portions  of  bowel.  If  performed  after  resection,  the 
end  of  the  colon  is  first  stitched  up,  then  an  incision  of  suitable 


ANASTOMOSIS  311 

length  is  made  into  the  side  of  the  blind  end  of  the  colon,  and 
about  one  to  two  inches  from  the  end  in  the  long  axis  of  the 
bowel.  A  guide  suture  is  then  inserted  taking  up  the  end  of 
this  incision  and  the  middle  of  the  side  wall  of  the  ileum,  a  similar 
suture  being  placed  on  the  other  side.  These  ensure  the  ends 
of  the  bowel  being  stitched  together  correctly,  and  are  useful  in 
holding  the  bowel  edges  in  position  during  suturing.  The  two 
edges  are  then  sutured  together,  taking  up  all  the  coats,  and  last 
of  all  a  protecting  peritoneal  line  of  suture  is  put  in  over  the  first, 
and  the  mesentery  is  stitched  together.     (See  Fig.  86.) 

Charters  Symonds  advises  using  a  Murphy's  button  for 
lateral  implantation.  The  shght  saving  of  time  obtained  by 
this  method,  however,  seems  insufficient  to  compensate  for  the 
increased  risk  of  introducing  a  foreign  body  into  the  colon. 

Ileo-sigmoidostomY. — This  may  be  done  either  by  lateral 
anastomosis  or  by  implantation  of  the  ileum  into  the  sigmoid 
flexure.  Lane,  who  has  been  one  of  the  chief  advocates  of 
ileo-sigmoidostomy,  advises  division  of  the  ileum  about  6  inches 
from  the  ileocaecal  valve,  and  implantation  of  the  proximal  end 
into  the  sigmoid  flexure  by  suture.  The  distal  end  of  the  ileum 
is  closed. 

If  the  patient  is  so  ill  as  to  render  a  short  operation  of  para- 
mount importance,  a  Murphy's  button  may  be  used  to  form  the 
junction  between  the  ileum  and  pelvic  colon  ;  but  in  skilled 
hands  there  is  little,  if  any,  saving  of  time  to  be  secured  by  this 
method.  It  is  important  to  carefully  stitch  together  the  meso- 
colon and  the  divided  edge  of  the  mesentery,  in  order  to  ensure 
that  no  gap  is  left  through  which  subsequent  strangulation  might 
occur. 

Shortening  of  the  Mesosigmoid. — This  operation  may  be 
done  to  prevent  the  recurrence  of  a  volvulus,  and  to  prevent 
acute  flexures  from  occurring  and  causing  obstruction  or  chronic 
constipation.  It  may  be  performed  in  cases  where  there  is  an 
abnormally  long  mesosigmoid,  and  is  attended  with  less  risk 
than  the  alternative  operation  of  resection  of  the  elongated  loop. 

A  series  of  Lembert  sutures  are  inserted  in  the  long  axis  of  the 
mesocolon,  and  parallel  with  one  another.  The  sutures  should 
all  be  inserted  on  one  side  of  the  mesentery  only,  preferably  on 
the  outer  side,  and  should  take  up  the  peritoneum  only,  special 
care  being  taken  to  avoid  wounding  the  veins  when  inserting  the 
sutures.     The  first  row  is  tied  up,  then  a  second  row  is  inserted 


312  RESTORING  THE  BOWEL 

over  these,  and  so  on,  until  the  mesocolon  has  been  sufficiently 
shortened.  As  a  rule,  it  is  found,  after  all  the  sutures  have  been 
tied,  that  a  kink  has  been  produced  in  the  colon  at  either  end  of 
the  line  of  sutures.  To  remedy  this,  a  few  more  Lembert  sutures 
should  be  inserted  opposite  the  kinks  in  such  a  way  as  to 
straighten  them  out.     (See  Fig.  32,  p.  91.) 

Colopexy. — This  operation  is  sometimes  performed  to  prevent 
the  reformation  of  a  volvulus,  or  to  cure  an  abnormal  kink  or 
angle  in  the  colon  which  is  causing  chronic  obstruction.  It  has 
also  been  done  in  some  cases  of  visceroptosis,  and  to  cure  prolapse. 

The  part  of  the  colon  which  requires  anchoring  is  usually  the 
sigmoid  flexure.  The  bowel  is  fixed  by  a  series  of  sutures  either 
to  the  walls  of  the  iliac  fossa,  or  in  some  cases  to  the  abdominal 
wall.  When  the  portion  of  the  bowel  has  been  selected  which 
it  is  proposed  to  fix,  the  peritoneum  should  be  scraped  or  in  part 
removed,  and  a  corresponding  portion  of  peritoneum  removed 
from  that  portion  of  the  abdominal  wall  or  iliac  fossa  to  which 
it  is  proposed  to  attach  it.  It  is  better  to  select,  if  possible,  the 
iliac  fossa,  as  this  is  fixed,  whereas  the  abdominal  wall  is  con- 
stantly moving.  The  selected  and  prepared  portion  of  colon  is 
next  secured  to  its  prepared  bed  by  sutures.  These  sutures 
must  be  very  carefully  inserted  with  fine  peritoneal  needles,  care 
being  taken  not  to  perforate  the  bowel-wall,  but  at  the  same 
time  to  obtain  a  good  hold.  It  is  also  necessary  to  see  that  the 
blood-supply  is  not  interfered  with,  or  the  bowel  kinked. 

Colopexy  does  not  appear  to  be  very  satisfactory,  as  in  several 
instances  in  which  it  has  been  performed  to  prevent  the  reforma- 
tion of  a  volvulus  it  has  failed,  and  at  a  subsequent  operation 
the  bowel  has  been  found  free  and  with  no  trace  of  the  previous 
fixation. 

METHODS      OF      RESTORING      THE      BOWEL      AFTER 

RESECTION     OF     GROWTHS    JUST     ABOVE     THE 

RECTO-SIGMOIDAL    JUNCTION. 

It  often  happens,  after  resecting  a  growth  at  the  lower  end  of 
the  pelvic  colon,  that  it  is  not  possible  to  deal  with  the  ends  of 
the  bowel  by  any  of  the  ordinary  methods.  The  lower  stump 
is  too  short  to  reach  the  skin,  and  owing  to  its  immobiUty,  and 
position  at  the  back  of  the  pelvis,  it  is  impossible  to  perform 
anastomosis,  although  the  upper  stump  of  colon  is  quite  long 
enough  to  reach  it. 


AFTER    RESECTION    OF    GROWTHS      313 

There  are  two  methods  by  which  the  bowel  can  be  restored 
under  such  circumstances.  If  the  upper  stump  is  long  and  has  a 
long  mesentery  (not  less  than  5  inches),  the  surgeon  can  free 
the  lower  stump  all  round  from  the  abdomen,  and,  by  making 


Sigmoid. 


Recto-sigiiioidal 
junction. 

Growth. 


fi'ig:  87. — Photograph  of  the  parts  removed  by  abdomino-perineal  e.vcision  for  cancer  at  the 
recto-sigmoidal  junction.  The  specimen  includes  the  whole  rectum  and  half  the  sigmoid  flexure. 
It  measured  14  inches  in  length.  The  patient  made  a  good  recovery,  and  had  excellent 
control  over  the  new  rectum,  which  was  formed  by  bringing  down  the  stump  of  the  sigmoid 
flexure  and  stitching  it  to  the  anus.     {Author's  case). 


an  incision  in  the  perineum,  excise  the  entire  lower  portion  of 
bowel,  in  fact,  perform  abdomino-perineal  excision  of  the  rectum, 
bringing  the  stump  of  the  sigmoid  down  to  the  anus  and  fixing 


314  RESTORING  THE  BOWEL 

it  there.  This  is  a  formidable  operation,  but,  if  successful,  it 
gives  very  good  results.  A  photograph  is  appended  {Fig.  Sy) 
showing  the  parts  removed  in  such  a  case.  The  patient  recovered 
and  had  excellent  control  over  the  bowel. 

Another  method  of  deahng  with  such  cases,  and  one  which  is 
simpler  and  does  not  involve  the  removal  of  a  normal  rectum,  is 
as  follows  : — After  the  growth  has  been  resected,  a  long  glass 
tube  or  one  of  the  author's  rubber  tubes  is  tied  into  the  upper 
stump  of  the  pelvic  colon,  and  the  free  end  of  this  tube  is  then 
passed  into  the  lower  stump  and  pushed  down  until  it  can  be 
♦  drawn  out  of  the  anus  by  an  assistant.  The  edges  of  the  lower 
stump  are  made  to  invaginate,  so  that  the  peritoneal  surfaces 
of  the  two  portions  of  bowel  come  into  contact.  A  few  sutures 
are  then"  inserted,  if  possible,  to  fix  the  two  portions  of  bowel 
together,  and  the  abdominal  wound  is  closed.  The  hne  of 
junction  cannot  leak  until  the  tube  separates,  and  by  that  time 
firm  union  should  have  taken  place.     (See  Fig.  88.) 

The  condition  produced  is  practically  a  short  artificial  intus- 
susception, the  two  peritoneal  coats  being  in  apposition,  and  the 
ends  of  the  mucous  coats  close  together,  though  not  necessarily 
touching  each  other.  Owdng  to  the  glass  tube  tied  into  the  upper 
portion  of  the  bowel,  no  leakage  can  occur,  and  the  ends  of  the 
bowel  have  about  a  week  in  which  to  become  united  to  each 
other  before  there  is  any  possibility  of  strain  being  thrown  upon 
the  line  of  union  ;  while  the  tube  is  stiD  in  position  the  bowels 
can  be  freely  opened  without  any  risk  of  leakage,  and  this  is  a 
very  great  advantage  in  the  case  of  an  anastomosis  so  near  the 
rectum. 

The  following  is  an  instance  in  which  this  operation  was  per- 
formed with  successful  results  : — 

Case. — I  saw  the  patient,  a  man,  aged  53  years,  on  Oct.  i8th, 
1907,  on  account  of  haemorrhage  from  the  bowel.  His  history  was  that 
for  nearly  twelve  months  he  had  been  passing  mucus  and  occasionally 
blood,  and  had  had  attacks  of  pain  in  the  abdomen.  About  a 
month  previously  he  had  a  profuse  haemorrhage  from  the  bowel, 
and  this  had  occurred  again  the  day  before  I  saw  him,  and  had  been 
accompanied  by  severe  pain  in  the  abdomen  lasting  for  about  half 
an  hour.  On  examination  per  rectum  nothing  abnormal  could  be 
felt,  but  very  high  up  a  large  resisting  mass  could  be  felt  through 
the  anterior  rectal  wall.  Under  ether,  by  bimanual  examination, 
and  after  stretching  the  sphincters  so  as  to  allow  of  two  fingers 
being  inserted  into  the  rectum,  a  gro^\i;h  could  be  distinctly  felt  in 


AFTER    RESECTION    OF    GROWTHS      315 

the  lower  part  of  the  sigmoid  flexure.     This  diagnosis  was  confirmed 
by  sigmoidoscopy. 

The  operation  was  performed  on  Nov.  4th.  The  patient  was 
anaesthetized  with  ether  by  the  open  method.  The  patient  having 
been  placed  in  the  Trendelenburg  position,  an  incision  was  made 
through  the  outer  part  of  the  rectus  sheath  on  the  left  side  of  the 
abdomen  and  extending  right  down  to  the  pubes.  On  opening 
the  abdomen  I  found  that  the  lower  part  of  the  growth  extended 
down  to  within  one  and  a  half  inches  of  the  recto-sigmoidal  junction, 
and  that  a  loop  of  the  sigmoid  flexure  above  the  growth  had  become 
adherent  to,  and  was  involved  in,  it.  This  necessitated  the  removal 
of  all  but  a  few  inches  of  the  sigmoid  flexure  if  the  growth  was  to  be 
removed.     The   sigmoid   flexure   was   divided   above   the  involved 


8. — (S)  Sigmoid.     (R)  Rectum.     (G)  Glass  tube,  to  the  upper  end  of  which  the  sigmoid  is 
tied.     (B)  Piece  of  rubber  tube  to  prevent  glass  tube  from  slipping  up  into  rectum. 


loop,  and  the  mesosigmoid  was  stripped  up  from  the  posterior 
pelvic  wall  and  the  vessels  clamped  as  they  were  divided.  This 
procedure  was  rendered  necessary  by  the  fact  that  some  of  the 
glands  in  the  mesosigmoid  were  involved.  As  a  result  of  the 
stripping  up  of  the  peritoneum,  the  great  iliac  vessels  were  laid  bare. 
The  sigmoid  flexure  at  the  recto-sigmoidal  junction  was  now  divided 
an  inch  below  the  growth,  and  the  adherent  loops  were  removed. 
The  peritoneum  was  brought  together  by  stitches  over  the  posterior 
pelvic  wall,  and  all  bleeding  points  were  ligated.  At  this  stage, 
owing  to  the  rectum  not  having  been  properly  emptied  previously 
to  the  operation,  some  soiling  of  the  pelvic  peritoneum  unfortunately 
took  place.  Any  of  the  ordinary  methods  of  end-to-end  anasto- 
mosis  were  quite  impossible  owing  to  the  depth  of  the  wound  and 


3x6  RESTORING  THE   BOWEL 

to  the  fact  that  there  was  no  stump  of  bowel  below,  but  merely 
a  hole  in  the  pelvic  floor.  I  tied  a  glass  Keith's  tube  into  the  upper 
end  of  the  sigmoid  flexure,  and  passed  the  free  end  of  this  tube,  to 
which  a  piece  of  large-bore  rubber  tubing  had  previously  been 
attached,  down  into  the  rectum  from  the  abdominal  cavity.  An 
assistant  then  caught  this  with  forceps  introduced  per  anum,  and 
drew  it  out  of  the  anus.  By  drawing  on  the  Keith's  tube,  the 
upper  end  of  the  sigmoid  flexure  was  invaginated  into  the  upper 
end  of  the  rectum,  thus  forming  a  kind  of  intussusception.  Two  or 
three  silk  stitches  were  then  put  in  to  prevent  the  invagination  from 
coming  undone.  A  drainage-tube  was  then  inserted  and  the 
abdominal  wound  was  closed  in  separate  layers. 

The  bowels  were  freely  opened  with  calomel  on  the  third  day 
through  the  tube.  The  tube  separated  and  came  away  on  the 
seventh  day  ;  after  this  a  faecal  fistula  formed  along  the  track 
of  the  drainage  tube,  and  there  was  some  discharge  for  a  time,  but 
the  bowels  continued  to  act  by  the  rectum.  The  patient  made  a 
good  recovery  without  any  bad  symptoms,  and  although  the 
faecal  fistula  was  a  troublesome  complication,  it  soon  began  to  close, 
and  in  the  course  of  a  couple  of  weeks  only  allowed  a  little  flatus 
to  escape  occasionally  and  soon  healed. 

The  patient  is  quite  well  at  the  present  time,  two  years  after 
operation.  There  is  no  trace  of  a  stricture,  and  he  has  normal 
control  over  the  action  of  his  bowels. 

Resection  of  the  Entire  Colon. — I  believe  the  first  case  in 
which  this  operation  was  performed  successfully  was  one  in 
which  Lienthall,  an  American  surgeon,  resected  the  whole  colon 
for  multiple  adenomata.  The  operation  was  performed  on 
June  15th,  1900.  The  patient  was  a  woman,  aged  21,  whose 
colon  from  end  to  end  was  covered  internally  with  small  adeno- 
mata which  caused  dangerous  and  intractable  hemorrhage. 
The  operation  was  performed  in  two  stages,  and  the  patient 
recovered.  Arbuthnot  Lane  was,  however,  the  first  to  com- 
plete the  resection  at  one  operation.  He  has  performed  it  a 
considerable  number  of  times,  and  has  proved  that  it  can  be 
done  with  a  comparatively  low  mortality. 

The  technique  is  as  follows  : — A  large  median  incision  having 
been  made,  and  the  abdomen  opened,  the  ileum  is  divided  at  a 
point  about  five  or  six  inches  from  the  csecum.  A  hgature  is 
first  placed  round  the  ileum,  and  the  latter  is  then  divided  with 
a  cautery.  The  stunip  is  next  buried  in  the  proximal  bowel  by 
means  of  a  purse-string  suture.  Next,  the  adhesions  and  peri- 
toneum   which    bind    the  caecum    and   ascending  colon  to   the 


AFTER    RESECTION    OF    GROWTHS      317 

posterior  abdominal  wall  are  divided,  and  the  bowel  is  raised  until 
the  vessels  supplying  it  are  exposed.  These  are  seized  in  forceps 
and  ligatured.  The  transverse  colon  is  similarly  treated.  The 
vessels  are  first  controlled,  and  then  the  colon  is  freed.  The 
descending  colon,  and  as  much  as  is  considered  advisable  of  the 
sigmoid  flexure,  are  similarly  freed.  A  point  having  been  chosen 
in  the  sigmoid,  which  will  leave  a  long  enough  stump  after 
division  to  enable  the  anastomosis  to  be  performed,  the  bowel 
is  divided  at  this  spot,  the  lower  end  being  closed  in  the  same 
way  as  in  dealing  with  the  ileum.  The  whole  colon  is  now  free 
and  can  be  removed.  The  closed  end  of  the  ileum  and  the 
closed  stump  of  the  sigmoid  are  then  brought  together  and 
joined  by  lateral  anastomosis.  Lastly,  the  edge  of  the  mesentery 
of  the  ileum  is  stitched  to  the  edge  of  the  mesosigmoid,  so  as  to 
prevent  there  being  any  gap  through  which  bowel  might  prolapse 
and  become  strangulated.  Mr.  Lane  passes  a  fine  gut  ligature 
through  the  free  incised  margin  of  the  mesentery  of  the  ileum, 
and  then  beneath  the  peritoneum  forming  the  outer  wall  of  the 
mesorectum.  When  this  is  tied  it  brings  the  rectum  to  the 
middle  line  of  the  pelvis  and  fixes  it  in  that  situation.  The 
■operation  may  also  be  performed  in  two  stages,  by  first  doing  an 
ileo-sigmoidostomy,  and  later  resecting  the  colon. 


3i8 


INDEX 


Abdomen,  palpation  of  the 
Abdominal     muscles,      exercises 

for  strengthening  the  . . 
Abnormalities,  congenital 
Abscess,  as  complication  of  ulcer- 
ative colitis 

—  a  result  of  pericolitis  193, 
Absorption  of  food  constituents 

by  the  colon 
Acute  dilatation  .  . 
Adeno-carcinoma 
Adenomata,  multiple 

—  villous 
Adhesions  following  pericolitis 

—  a  cause  of  constipation 

—  and  kinking    . .  . . 

symptoms 

treatment 

Age  incidence  in  volvulus 
Amoebic  dysentery 
Aucesthetic,  examination  under 
Anastomosis,   spontaneous,   from 

cancer  of  colon 

—  technique  of  . .  . .  29 
Anatomy  and  development 
Animals,  variations  of  the  colon  in 
Antiperistalsis 
Anus,  artificial,  closure  by  oper 

ation 

—  —  operation  to  form 
Appendices      epiploicas      causing 

constriction 
Appendicitis  a  cause  of  kinking 

—  causing  mucous  colitis 
Appendicostomy  for  chronic  co 

litis 

—  catheter 

—  for  constipation 

dilated  colon 

haemorrhagic  colitis 

—  opening,  to  close 

—  technique  of  . . 

—  in  tuberculosis 

—  —  ulcerative  colitis 
Arsenic  in  chronic  colitis 
Arterial  circulation 

—  thrombosis  a  cause  of  meteor 

ism. . 
Arteries,  embolism  of  colic 
Artificial  anus,  closure  by  oper 

ation 

—  —  operation  to  form 


PAGE 

43 


224 
58 

178 


14 

32 

249 

237 

237 

194 

95,  221 

92 

94 
102 

87 
156 

55 

260 
307 


291 
280 


135 

145 
296 
227 

74 
169 
299 
294 
214 
174 
141 

4 

32 
235 

291 

280 


page; 
Artificial  anus,  physiological  re- 
sults of       . .           .  .           . .  29' 

—  —  in  ulcerative  colitis         . .  174 
Asylum  dysentery           . .          . .  156- 

Bacillus  bulgaricus       . .          . .  38- 

—  —  in   preparing   patient    for 

operation  . .          . .          . .  303 

—  coli       . .          . .          . .          . .  38 

—  dysenterise       . .           . .           . .  154 

—  of  tubercle       . .          . .          . .  40 

Bacteria   in    colon,    modification 

in  preparing  for  operation  303 

Bacteriology  of  the  colon           . .  37- 

—  —  ulcerative  colitis               . .  156 
Bailey's  modification  of  Witzel's 

colotomy   . .          . .          . .  283 

Belladonna  in  chronic  colitis      . .  141 

enterospasm          . .          . .  153 

Bismuth  in  X-ray  diagnosis      . .  51 
Blood  in  stools,  diagnostic  impor- 
tance of     . .           . .           . .  57 

Blood-supply,   interference  with, 

a  cause  of  meteorism       . .  32 

Blood-vessels        . .          . .          . .  4 

Bougies  and  tubes  in  diagnosis  . .  55 

Bulgarian  bacillus            . .           . .  38- 

—  —  in    preparing    patient    for 

operation  . .          . .          . .  303 

C^cosTOMY  for  chronic  colitis  . .  144 

—  —  irrigation  of  colon            . .  300- 

—  technique  of  . .           . .           . .  289 

—  for  ulcerative  colitis             . .  174 
Caecum  as  an  organ  of  digestion  i 

—  volvulus  of      . .           . .           . .  83 

Cancer        .  .           . .           . .           . .  249 

—  associated  with  pericolitis    . .  195 

—  a    cause    of    chronic    mucous 

colitis         . .           . .           . .  136 

— intussusception           . .  120 

—  indications  for  removing      .  .  267' 

—  lines  of  extension  of  growth  253 

—  morbid  anatomy        . .           . .  250 

—  palliative  operations              . .  273 

—  predisposing  causes  .  .           .  .  250- 

—  recurrence  after  excision     . .  272 

—  secondary  results  of  . .           . .  260^ 

—  spontaneous  anastomosis  in  . .  261 

—  symptoms        . .           . .           . .  255 

—  treatment        . .          . .          . .  263; 


INDEX 


319 


290 
33 

28 

127 

95 

4, 127 
143 

■  132 
139 
12S 
167 
237 
201 
154 
156 
155 
157 
165 
161 
172 


Carbon  dioxide,  its  origin  in  acute 

dilatation  . . 
Catarrhal  colitis  causing  mucous 

colitis 
Cholin  in  the  faces 
Chronic  constipation 

—  —  treatment 

—  mucous  or  membranous  colitis 
Closure  of  ftecal  fistula  by  oper- 
ation 

CO2,  its  origin  in  acute  dilatation 
Colectomy,    physiological   results 

of    ..      "    .. 
Colica  mucosa 
Colitis,  caused  by  adhesions 

—  chronic  mucous  or  membran 

ous  . .  . .  2 

operations  for 

pathology  and  etiolo 

treatment 

—  —  —  symptoms 

—  hemorrhagic  . . 

—  polyposa 

—  tuberculous     . . 

—  ulcerative 

—  —  bacteriology 

—  —  etiology 

—  —  pathology 

—  —  prognosis   .  . 

—  —  symptoms 

—  —  treatment 

—  various  types  of  inflamm.ation 

137 
Colon,  length  of 

—  surface  markings  of  .  .  .  .  8 
Colopexy,  technique  of  .  .  312 
Colostomy  for  ulcerative  colitis  174 
Colotomy  . .           . .           .  .           . .  280 

—  in  cancer         . .           .  .           .  .  264 

—  closure  of         . .          . .          . .  290 

— ■  for  chronic  colitis       . .           . .  144 

congenital  dilatation  and 

hypertrophy   . .           . .  73 

■ —  inguinal,  technique  of           . .  281 

—  lumbar,  technique  of             .  .  285 

—  opening,   control  over 

—  as  palliative  in  cancer          . .  275 

—  Paul's  method            .  .           .  .  287 

—  preparation  of  patient  for   . .  302 

—  sensation  at  the  opening  after  15 

—  valvular           . .          . .          . .  283 

Congenital   abnormalities   of   the 

colon  .  .  . .  .  .  58 

—  —  peritoneum   or   mesentery  59 

—  causes  of  volvulus      . .  . .  78 

—  dilatation  and  hypertrophy. .  61 

—  —  —  diagnosis  of     .  .  . .  64 

—  —  —  etiology  of       .  .  . .  65 

—  —  —  morbid  anatomy  of 

—  —  —  prognosis  of    .  .  . .  72 

—  treatment  of  . .  . .  72 

Constipation,  adhesions  a   cause 

of  ..  ..  ••93 


AGE  PAGE 

Constipation,  atonic         . .           . .  220 

33       —  in  cancer         .  .           . .           . .  258 

—  chronic             . .           . .           . .  218 

137       —  —  operative  treatment        . .  226 

26       —  —  treatment               . .           . .  221 

218       —  exercises  for     ..          ..           ..  224 

221        —  use  of  X  rays  in  diagnosis  of  218 

127       Contents  of  the  colon      .  .           .  .  24 

Contractions  of  mesosigmoid  from 

pericolitis  .  .           .  .           .  .  ig6 

Croup,  mucous      . .           . .           .  .  127 


Deformities      of      mesosigmoid 

from  pericolitis     .  .           . .  196 

Development  of  the  Colon          .  .  9 
Diagnosis   by   means   of  bougies 

and  tubes              .  .           . .  55 

—  methods  of     . .           ..           ..  41 

—  the  sigmoidoscope  in            .  .  44 

—  X  raj'S  in        . .           . .           .  .  51 

Diarrhoea,   causes  of       . .           .  .  26 

—  membranous  or  mucous       . .  127 

—  in  multiple  polypi  of  the  colon  243 

—  in  ulcerative  colitis    . .           . .  161 
Diet  in  chronic  colitis    .  .           . .  141 

—  Von  Noorden's            . .          . .  141 
Dilatation,   acute             .  .           .  .  32 

—  and  hypertrophy,    congenital  61 

—  post-operative,  causes  of     . .  35 

—  resulting  from  cancer           . .  261 

—  secondary  results  of..  ..  68 
Distention  or  stercoral  ulcers  . .  i6g 
Diverticula  causing  pericolitis  ..  181 
Doyen's  method  of  anastomosis  309 
Dysentery,  bacillary,  and  ulcera- 
tive colitis             . .           . .  156 

—  stricture  after.  .           . .           . .  234 

—  tropical,  and  ulcerative  colitis  134 

Electrical  treatment  of  adhe- 
sions          . .          . .          . .  103 

—  —  chronic   constipation       . .  225 
Embolism  of  colic  blood-vessels  235 
End-to-end     anastomosis,     tech- 
nique of    . .           . .           . .  307 

Enteritis  membranacea              .  .  127 

Entero -colitis        . .           . .           . .  127 

Enteroliths  causing  chronic  con- 
stipation   . .           . .           . .  228 

Enteroptosis     causing     mucous 

colitis         . .           . .           .  .  135 

—  of  transverse  colon   . .           .  .  107 

Enterospasm         . .           . .           .  .  150 

Enterotome  for  closing  colotomy 

opening      . .          . .          . .  292 

Epicolic  glands    . .          . .          . .  7 

Examination  of  the  stools          . .  56 

Exercises  for  chronic  constipation  224 

Excision  of  bowel  for  cancer      . .  263 

— physiological  results  of  28 

Exploratory    laparotomy,    when 

indicated   . .          . .          . .  56 


320 


INDEX 


PAGE 

F^CAi,  calculi       . .          . .          . .  228 

—  fistula,  closure  by  operation  290 

—  impaction        . .           . .           . .  228 

symptoms..           ..           ..  230 

—  —  treatment              . .          . .  231 
Faeces,  acid  reaction  of    . .           . .  27 

—  bacteriological  content  of     . .  37 

—  colour  of          . .           . .           .  .  26 

—  examination  Crf           . .           .  .  56 

—  in  mucous  colitis       . .           .  .  130 

—  normal    and    abnormal    con- 

stituents in           .  .          . .  24 

Fat  in  the  stools  . .           . .           . .  25 

Fibrolysin  in  treatment  of  adhe- 
sions          . .           . .           . .  103 

Fistula,   faecal,   closure  by  oper- 
ation         . .          . .          . .  290 

Fistulae  following  pericolitis       .  .  194 
Flexner's  acid  bacillus  in  ulcera- 
tive colitis             . .           . .  156 

Foetus,  development  of  the  colon 

in  the         . .           . .           . .  9 

Follicular  ulceration        . .           . .  166 

Food  constituents,  absorption  by 

the  colon  . .           . .          . .  14 

—  indigestible,  a  cause  of  intus- 

susception..         ..           ..  120 

—  time  occupied  in  reaching  and 

passing  colon        . .           . .  19 

Functions  of  the  large  intestine  13 

Gangrene   causing  intussuscep- 
tion           . .          . .          . .  120 

Gas-pipe  colon     . .           . .           . .  212 

Glandular  system            . .          . .  7 

Glutinous  diarrhoea         . .           . .  127 

Granular  colitis  causing  chronic 

mucous  colitis      . .           . .  137 

Growths  in  pelvic  colon,  restoring 

bowel  after  resection  of  . .  312 

HEMORRHAGE  as  Complication  of 

ulcerative  colitis              . .  178 

Haemorrhagic  colitis        . .           . .  167 

Hepatic  flexure,  cancer  of          .  .  269 

Hernia  of  the  colon          ..           ..  in 

Hirschsprung's  disease    . .           . .  62 

History  as  guide  to  diagnosis    . .  41 
Hydrotherapy  in  chronic  consti- 
pation       . .           . .           . .  226 

Hyperplastic  tuberculosis          . .  202 
Hypertrophic  colitis  with  chronic 

mucous  colitis      . .           . .  137 

Hypertrophy  and  dilatation,  con- 
genital       . .           . .           . .  61 

Hyrax,   arrangement  of  the  cae- 
cum in  the           . .           . .  2 

Idiopathic  dilatation     . .          . .  62 

Iguana,  function  of  caecum  in  the  i 

Ileocsecal  angle,  cancer  of          . .  255 

—  artery  and  its  branches         .  .  5 

—  valve,  anatomy  of     . .          . .  3 


Ileo-colostomy    as    palliative    in 

cancer 
Ileo-sigmoidostomy    for    chronic 

colitis 

—  for  chronic  constipation 

—  —   dilated  colon 

—  methods  of     . . 

—  physiological  results  of 
Indicanuria,  Obermeyer's  test  for 
Inflammation     causing     chronic 

mucous  colitis 

Inguinal  colotomy 

Injection  treatment  of  intussus- 
ception 

Injury  to  the  colon  in  animals, 
sensory  effect  of 

—  —  effect  of  experimental 
Intestinal  sand     . .  .  .  25, 
Intra-abdominal     pressure,     to 

restore 
Intussusception    . . 
— -  etiology 

—  experimental  . . 

—  pathology 

—  prognosis 

—  spontaneous  elimination  of 

—  symptoms 

—  treatment 
Irrigation   of  colon,   appendicos 

tomy  for 

caecostomy  for 

fluid  used  in 

Kinking  and  adhesions.. 

Lactic  acid  bacilli 

—  —  ferment       in       preparing 

patient  for  operation  . 
Lane's  method  of  anastomosis  . 
Laparotomy,    exploratory,    when 

indicated   . . 
Lateral    anastomosis,    technique 

of 

—  implantation  of  bowel 
Lemur,  arrangement  of  the  colon 

in  the 
Lienteric  diarrhoea,  causes  of 
Lumbar  colotomy 
Lymphatics 

Madelung's  method  of  anasto- 
mosis 

Malformations  giving  rise  to 
volvulus     . . 

Malignant  disease 

causing    chronic    mucous 

colitis 

Massage  for  adhesions    . . 

—  chronic  constipation  .  . 
Membranous  colitis 

Mental  condition  in  mucous 
colitis 


274. 

145 

228- 

75 

311 

28 

57 

137 

281 

124 

15 
15 

131 

109 
114 
115 
115 
120 
126 
121 
122 
124 

294 
300 
297 

92 

38 

303 
309 

56 

309 
310 


26 

285 
5 


309 

78 
249 

136 
102 

223 
127 

130 


INDEX 


321 


PAGE 

Mesentery,       abnormalities       of, 

causing   volvulus             . .  78 

—  congenital  abnormalities  of    .  .  59 

—  development  of  the              . .  11 
Mesocolon,  operation  for  shorten- 
ing                92 

—  method    of   dealing  with,  in 

resection    . .          . .          . .  306 

Mesosigmoid,      deformities      and 
contractions     following 

pericolitis  . .           . .           . .  196 

—  operation  for  shortening  the  311 
Meteorism              . .           . .           . .  32 

—  post -operative,  causes  of  . .  35 
Methods  of  diagnosis       . .           . .  41 

—  —  restoring  the  bowel  after 

resection  of  growths  . .  312 
Micro-organisms     in     intestinal 

contents     . .          . .          . .  37 

Monkeys,  the  cagcum  in               . .  i 

Morbid  physiology           . .           . .  28 

Mucous  or  membranous  colitis  .  .  127 

—  secretion  and  diarrhcea  .  .  26 
Mucus,  diagnostic  importance  of  56 

—  normal  presence  in  colon       24,  56 
Multiple  polypi    . .          . .           . .  237 

Murphy's  button  in  anastomosis 

268,  307 

Nerve  supply      . .           . .           . .  14 

Nervous    symptoms    in    mucous 

colitis         . .           .  .           . .  130 

Neurin  in  the  faeces       . .           . .  26 

Neurosis  theory  of  mucous  colitis  132 

Normal  contents  of  the  colon  . .  24 
Nothnagel's    neurosis    theory    of 

mucous  colitis      . .          . .  132 

Obermeyer's  test  for  indicanuria  57 
Obstruction  due  to  cancer,  treat- 
ment by  operation           . .  263 

—  chronic,    from   angulation   or 

kinking      . .          . .          . .  96 

Occlusion  of  colon,  physiological 

results  of  . .          . .          . .  28 

Olive  oil  in  chronic  colitis          . .  140 

Omentum,  development  of  the. .  11 
Operation,  preparation  of  patient 

for  . .          . .           . .           . .  302 

Orang-utang,  the  caecum  in       . .  i 

Pain  in  the  colon  only  indirect  . .  15 

Palpation  of  the  abdomen         . .  43 

Paracolic  glands               .  .           . .  7 

Patient,  preparation  of,  for  oper- 
ation          . .          .  .           . .  302 

Paul's  method  of  colotomy        . .  287 

—  operation  in  cancer  . .  . .  265 
Pelvic  colon,  anatomy  of           . .  9 

—  —  volvulus  of  . .  . .  83 
Percussion  of  the  abdomen  . .  43 
Perforating  pericolitis,  treatment  199 

—  ulcer,  treatment         . .          . .  176 


PAGE 

Perforation  causing  pericolitis..  188 

—  of  colic  ulcer..           ..          160,  170 
Pericolitis              . .           .  .           . .  179 

—  etiology            . .           . .           .  .  180 

—  diverticula  causing     . .           . .  186 

—  pathological  conditions  arising 

from           . .           . .           . .  igr 

—  symptoms        . .           . .           .  .  189 

—  treatment        . .          . .          . .  197 

Peristalsis,  effect  of  colonic  con- 
tents on     . .           . .           .  .  17 

—  causes  of          . .          . .          . .  19 

—  experimental  . .           . .           . .  17 

—  rate  of              . .          . .          . .  21 

Peritoneum,      abnormalities     of, 

causing  volvulus  . .          . .  78 

—  congenital  abnormalities  of  . .  59 
Peritonitis,  adhesions  following  93. 

—  as  a  cause  of  acute  dilatation  34. 

—  general,    following   pericolitis 

196,  199 

Petroleum  in  chronic  colitis       . .  142 

—  chronic  constipation              . .  222 
Physiology             . .           . .           . .  13 

—  morbid             . .           . .           . .  28 

Polypi     associated     with     other 

conditions . .          . .          . .  246 

—  cancerous         . .          . .          . .  259 

—  malignant  tendency  . .          . .  242 

—  multiple           . .           . .           .  .  237 

—  —  symptoms..          ..           ..  243 

—  —  treatment              . .          . .  246 

—  predisposing  to  cancer         250,  253 
Polypus  as  the  starting-point  of 

intussusception     ..          ..  117 
Post-operative  meteorism,  causes 

of 35 

Preparation  of  patient  for  oper- 
ation         . .          . .          . .  302 

Re-absorption  of  water  by  the 

colon          . .          . .          . .  13 

Rectal  bougies  and  tubes  in  diag- 
nosis    55 

Rectum,  the  normally  empty  state 

of        23 

Resection    and    anastomosis    of 

colon        . .         . .         . .  302 

—  —  multiple  polypi    . .           .  .  248 

—  —  physiological  results  of  . .  28 

—  of  dilated  colon          . .          . .  74 

—  entire  colon,  technique         . .  316 

—  growths,  restoring  the  bowel 

after           . .           . .           . .  312 

Reversal  of  colon,  experiments  in  23 

Rupture  of  colon            . .          . .  276 


Saline  infusion  in  operations 
Sand,  intestinal    .  . 
Sarcoma     . . 
Segmentation 
Sensory  nerves     . . 


305 
25 

262 
22 
15 


322 


INDEX 


Shiga's    bacillus     dysenteriae    in 

ulcerative  colitis  . .  156 
Shock  in  operation,  prevention  of  305 
Sigmoid  flexure,  anatomy  of  . .  9 
cancer  of  . .           . .         255,  270 

—  —  on  right  side  . .  . .  60 
Sigmoidoscopy,  technique  of  . .  44 
Simple  stricture  of  the  colon      . .  233 

—  tumours           . .           . .           . .  237 

Spasmodic  stricture  of  the  colon  150 

Splenic  flexure,  cancer  of  . .  269 
Stercoliths  in  diverticula  causing 

pericolitis  . .           .  .           . .  185 

StercoUtis               .  .           .  .           - .  228 

Stercoral  calculi   . .          . .          . .  228 

—  ulcers    . .          . .           . .           . .  169 

Stools,   examination  of  .  .           . .  56 

—  in  mucous  colitis  . .  . .  130 
Strauss's  sigmoidoscope..  ..  44 
Stricture     of     the     colon,     non- 

-^         malignant              ..           ..  233 

—  following  pericolitis  . .           . .  194 

—  polypi  associated  with  . .  246 
Symptoms,    method    of    inquiry 

into             . .          . .          . .  41 

Syphilis 188 

Thrombosis  causing  meteorism  32 

—  or  embolism  of  blood-vessels  235 
Toxins  in  obstructed  bowel  .  .  26 
Transverse  colon,  cancer  of      255,  269 

enteroptosis  of     . .          . .  107 

Traumatism          . .          . .          . .  276 

—  a  cause  of  pericolitis  ..  ..  188 
Tropical  dysentery  and  ulcerative 

colitis         . .           .  .           . .  154 

Tubercle  bacillus             . .           . .  40 

Tuberculosis          . .           . .           . .  201 

— •  morbid  anatomy        . .           . .  205 

—  hyperplastic    . .           . .           .  .  202 

—  —  polypi  associated  with    . .  246 

—  symptoms        . .           .  .           . .  209 

—  treatment        . .           .  .           .  .  214 

Tuberculous  ulceration  . .           .  .  172 

Tumour    formation    from    peri- 
colitis . .  . .         igr,  199 


—  —  —  tuberculosis 
Tumours,  simple . . 


204,  205 
•  •      237 


PAGE 

Tuttle's  method  of  colotomy     . .      283 
Typhoid  ulceration         . .  . .      177 

Ulcer,  simple  perforating  . .  170 

Ulceration  causing  pericolitis  . .  188 

—  tuberculous     . .           . .  . .  201 

Ulcerative  colitis..          ..  ..  154 

operative  treatment  of  . .  173 

—  —  perforation  in        . .  . .  160 

—  —  polypi  associated  with  . .  246 
Ulcers  of  colon,  natural  healing  of  164 

—  distention  or  stercoral  .  .  169 
Urine,  examination  of     ..  ..  57 

Vaccine  treatment  of  ulcerative 

colitis 
Value  of  the  colon 
Valve,  ileocsecal    .  . 
Vascular  system  . . 
Veins,  embolisms  of  colic 
Venous    thrombosis    a   cause    of 

meteorism . . 
Vesico-colic  fistula  following  peri 

colitis 
Vibration  and  massage  iu  chronic 

constipation 
Villous  adenomata 
Visceroptosis 
Volvulus,  acute,  symptoms  of 

—  —  treatment  of 

—  of  cffical  angle . . 

—  chronic,  symptoms  of 
■ —  —  treatment  of 
— •  compound 

—  etiology  of 

—  pathology  of  . . 
—  prevention  of  recurrence  of 

Von    Noorden's    diet    in    chronic 

colitis         . .  . .  . .      141 

Water,     re-absorption    by     the 

colon          . .           . .           . .  13 

Witzel's  operation  for  colotomy  283 

Wounds  of  colon             . .           . .  276 

X  RAYS  in  diagnosis        .  .  .  .        51 

•  —  of  chronic  constipation     218 

observation  of  peristalsis         19 


172 

14 

3 

4 

235 

32 

194 

224 
237 
107 
76 
87 
83 
71 
91 
87 
78 


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